woman taking finger prick

A glycated hemoglobin A1c test (HbA1c), is a blood test that is typically taken in a laboratory, or at home, which measures your average blood glucose levels over the previous 2-3 months, the lifespan of a red blood cell.  This is a standard test that people with prediabetes and type 2 diabetes routinely get to assess the overall management of their blood sugar levels and to course-correct ongoing diabetes treatment plans.

The HbA1c test shows how much glucose is attached to hemoglobin, a protein found in red blood cells.  This protein is what gives blood its red color. The higher amount of glucose attached to the red blood cells, the higher the HbA1c level. Conversely, the HbA1c levels decrease when less glucose is attached to the red blood cells.

It is well known what the consequences are of higher than normal HbA1c levels. For example, an HbA1c level of 9%, or, the equivalent of an average blood sugar level of 212 mg/dl, can start to put you at risk for diabetes complications later on in life.

According to the American Diabetes Association’s Standards of Medical Care in Diabetes, 2022, an HbA1c of 9% puts one at a higher risk for blindness, heart attack, nerve damage, hypertension, and kidney failure. Therefore, the higher your HbA1c level, the more dangerous it is and the more likely you are to suffer from long-term diabetes complications.

While there is a plethora of information out there about the dangers of a high HbA1c, there isn’t much information about the risks of a low HbA1c.  This can lead to confusion as to what level is actually dangerous and what to do about it when a low blood sugar episode occurs.

For most people, a safe HbA1c level generally lies anywhere between 5-8%, although this will vary per person. An HbA1c that is routinely under 5%, however, can pose a danger of too many and too severe low blood sugars episodes, called hypoglycemia, which can ultimately cause diabetic coma and death.

This article will investigate the risks of having HbA1c levels at 5% and lower, and what to do about improving yours if you find yourself consistently at this dangerous level.

Importance of Regular Healthcare Consultation and HbA1c Measurement

  1. An HbA1c test helps in the diagnosis of diabetes:

The HbA1c test is an important tool for diagnosing prediabetes, type 1 and  type 2 diabetes, and even sometimes gestational diabetes.  This test can be performed in the lab, or you can test your HbA1c at home.

Your healthcare team may recommend you get an HbA1c test if you’re under the age of 45 but have certain risk factors for diabetes, including:

  • Being overweight or obese
  • Having a family history of diabetes
  • Having hypertension (high blood pressure)
  • Previously had gestational diabetes
  • Are an ethnic minority
  • Having heart disease
  • Live a sedentary lifestyle/physical inactivity

You should call your care team right away if you experience the following symptoms, as they are signs of diabetes:

If your results reveal prediabetes, you should talk with your healthcare team about steps you can take to reduce your risk of developing full-blown type 2 diabetes. Also, your care team will more than likely recommend that you get a repeat HbA1c test done annually or semi-annually. Additionally, for people 45 and older, the Centers for Disease Control and Prevention (CDC) recommend an HbA1c test every 3 years.

Further, your care team may recommend you get an HbA1c test or seek emergency medical care, if your symptoms are severe and dire.

  1. An HbA1c test determines general diabetes control:

For people with existing prediabetes or type 2 diabetes, a quarterly HbA1c test is usually ordered to determine your average blood sugar levels, and general blood sugar control, over the previous 3 months. HbA1c tests are a great tool in detecting if your blood sugar levels are running too high or low, and can help you change your diabetes management plan without the need for diabetes-related medications. This includes a healthy nutritional plan, or even vitamin supplementation if desired, to help prevent future complications.  Since an HbA1c test is merely an average of your previous 3 months’ blood sugar levels, however, it will average out all of the high blood sugar levels with all of the low blood sugar levels. This can potentially give you a false sense of accomplishment if, in fact, your blood sugar levels are wildly fluctuating and you are unaware of this. If you are monitoring your blood sugar levels daily and they are moderately stable, however, this test can give you a sense of how well you are managing to keep your blood sugars in your particular target range.

What Are The Different HbA1c Levels?

The American Diabetes Association (ADA)  uses the following definition to determine if you have type 2 diabetes or prediabetes:

Normal, no diabetesHbA1c below 5.7%
PrediabetesHbA1c between 5.7% and 6.4%
DiabetesHbA1c of 6.5% or higher

Individual HbA1c goal levels will vary by person. For example, for someone who has hypo unawareness-has trouble detecting their low blood sugars episodes- or for someone living with type 2 or prediabetes who lives by themselves, their doctor may recommend a slightly higher HbA1c goal.

On the other hand, for someone with existing type 2 diabetes who is also pregnant, an HbA1c of or below 6% is ideal, as long as they’re not experiencing too many low blood sugar episodes.

The American Diabetes Association generally advises HbA1c levels to stay below 7% to help prevent diabetes complications for adults, and below 7.5% for children.

A HbA1c Level of 5% or Lower-a Risky Scenario

There are important risks to be aware of in having a too-low HbA1c level. In saying this, a wise practice is to be in regular contact with your healthcare team to see what unique HbA1c level should be the goal to achieve, depending on your lifestyle, health goals, and age.

An HbA1c level lower than 5% is a rather dangerous range that would be best to avoid. While diabetes management is becoming more precise with more efficient medications on the market, better access to diabetes self-management education, and, for some people living with type 2, continuous glucose monitoring (CGM) systems, people living with diabetes are achieving lower HbA1cs than ever before. 

Of course, this is a fantastic achievement if you’re not experiencing too many low blood sugars episodes.

On the other hand, it can still be dangerous to have an HbA1c under 5%.

A 5% HbA1c level or lower indicates that your average blood sugar over the past three months is only around 97 mg/dL. So, if your HbA1c test indicates a level lower than 5%, that may be an indicator that you’re having too many low blood sugar level episodes.

Understanding The Effects of Low HbA1c Levels

Having consistent blood sugar levels around 97 mg/dl could cause serious health risks including:

  • Risk of fainting and/or falling from a moderate walk or hot shower
  • diabetic coma
  • Death

Ways To Make Your HbA1c Safer if it’s Too Low

To increase your HbA1c if you’re falling into the low danger zone, your healthcare team may propose the following:

  1. An adjustment in your medication dosage
  2. A decrease in the amount of exercise, or, an adjustment in the type of exercise you do, if you’re struggling with constant lows after physical activity
  3. An increase the amount of protein and fat in your diet to help prevent low blood sugar episodes, especially overnight
  4. If you don’t already have one, and you are eligible, ask your healthcare team to set you up with a CGM to catch low blood sugar levels before they become dangerous

While there is no “perfect” HbA1c level, no one should have to live with a harmful HbA1c level that could be detrimental to one’s health and well-being long term. If you have concerns about your current HbA1c level, always reach out to your healthcare team.

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