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HbA1c: why it pays to be a smooth operator

What you lose on the swings, you gain on the roundabouts’ is an old-fashioned phrase describing a relaxed approach to life. Whatever happens along the way, the outcome will probably be OK.

Do you ever feel this way about your HbA1c? There might be ups and downs in your glucose levels day by day, but as long as the overall measure is in target range, it’s fine?

Most people with diabetes are encouraged to focus on lowering their HbA1c, and with good reason: evidence shows controlling HbA1c significantly reduces the risk of developing diabetes complications. 1,2

But what happens day by day is also important for long-term health and wellbeing. This is why we want to introduce you to a new clinical approach to the way you manage your diabetes: The Triangle of Diabetes Care. It takes into account not just one treatment goal, but three:

• Improving HbA1c

• Reducing hypos

• Limiting glucose variability

In previous articles we’ve looked at why improving HbA1c and reducing the frequency of hypos are the first two points of The Triangle of Diabetes Care.

But why is limiting glucose variability – avoiding wide swings between low and high glucose – the third treatment goal?

Short-term swings and long-term health

On a day-to-day basis, avoiding daily high and low blood sugars is clearly a good idea. No one wants to spend their days chasing their glucose in response to individual high and low readings.

But research also shows in the long term, independent of HbA1c, wide daily swings in glucose levels before and after meals are linked to an increasing risk of diabetes complications. 3,4,5,6

For example, the DCCT, an important long-term trial, found people with type 1 diabetes whose glucose levels varied widely through the day were more likely to develop cardiovascular disease than those with steadier levels. 3

Other more recent studies have found artificially induced swings from low to high blood glucose also produce more oxidative stress in the body, which may increase the risk of coronary heart disease and stroke. 7,8

This is why the third point of The Triangle of Diabetes Care is about paying attention to trends in high blood sugars, spotting why they might occur and feeling confident about what action to take to prevent them where possible. And of course, if you’re controlling highs and avoiding lows, you’re also taking steps to improving your HbA1c.

But how does the science translate into practical tips you can use in your everyday diabetes management? FreeStyle Progress includes an educational programme and guide to The Triangle of Diabetes Care. It will help you understand how your FreeStyle blood glucose meter or reader can help you work towards all three treatment goals. It’s free and it only takes a minute to register! What are you waiting for?


1. DCCT: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group New England Journal of Medicine 1993; 329: 977-986

2. Stratton MI et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. British Medical Journal 2000; 321: 405-412

3. Kilpatrick ES et al. Mean blood glucose compared with HbA1c in the prediction of cardiovascular disease in patients with type 1 diabetes. Diabetologia 2008; 51: 365-371

4. Lin CC et al. Variation of fasting plasma glucose: a predictor of mortality in patients with type 2 diabetes. American Journal of Medicine 2012; 125: 416.e9-18

5. Hanefeld M et al. Risk factors for myocardial infarction and death in newly detected NIDDM: the Diabetes Intervention Study, 11 year follow up. Diabetologia 1996; 39: 1577-1583.

6. Muggeo M et al. Fasting plasma glucose variability predicts 10-year survival of type 2 diabetic patients: the Verona Diabetes Study. Diabetes Care 2000; 23:45-50.

7. Ceriello et al. Oscillating glucose is more deleterious to endothelial function and oxidative stress than mean glucose in normal and type 2 diabetic patients. Diabetes 2008; 57: 1349-1354

8. Ceriello et al. Hypergylcaemia following recovery from hypoglycaemia worsens endothelial damage and thrombosis activation in type 1 diabetes and in healthy controls. Journal of Nutrition, Metabolism and Cardiovascular Disease 2014; 24: 116-123.


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