What habits do people with optimal blood glucose levels have in common? What about those who are struggling to get to their goals?

To shed light on the answers, we are excited to share our first-ever data-driven journalism article! We surveyed almost 2,000 people who are living with or caring for someone with diabetes to identify “the habits of a great A1c.” (An HbA1c blood test helps reveal your average blood glucose levels during the prior three months.)

Survey: Habits of a Great A1c

We have been eager to tap into our new diabetes research panel. The Thrivable Insights database includes 20,000 people with diabetes living in the United States. We use it to conduct surveys, phone and web-based focus groups, and other types of research to gather important insights into various aspects of living (and thriving) with diabetes. You can learn more and join the panel here.

We queried Thrivable Insights panel members to learn more about what habits are common to those who achieve optimal A1c levels. We asked detailed questions about various aspects of management, including meal planning and patterns (e.g., carbohydrate intake habits), insulin use strategies, exercise habits, technology use, healthcare provider visits, socioemotional factors, and much more! Next, we evaluated the responses as they related to the patients’ A1c levels.

Data Analysis

After the survey was completed, we segmented the data to examine separately the information reported by type 1 diabetes patients and caregivers vs. type 2 diabetes patients and caregivers. We examined the differences between specific habits of survey participants who reported an A1c of <6.5% vs. those who reported an A1c of >8.0%. Specifically, we analyzed the differences in the proportion of individuals who reported a particular habit using a comparison of proportions calculator to identify the statistically significant differences between the groups.

Study Strengths and Limitations

The strengths of this study include the robust sample sizes across all analyses, as well as a rigorous survey design and data analysis processes.

The main limitation of the study is that all the data (including the A1c levels) are self-reported. Also, while the specific statistical analysis performed can be used to infer an association between a particular habit and A1c level, it does not serve to correlate a particular habit with any outcome.

Finally, while we analyzed patients with type 2 and type 1 diabetes separately, we did not account for differences in patient age, sex, diabetes duration, or socioeconomic status in this initial set of analyses. Notably, approximately 75% of the respondents were female. We look forward to examining the data further in the near future to learn about what effects these demographical differences may have on the results.

Data Report

Demographic Information

N total = 1,938

Male = 25%

Female = 75%

Type 1 Diabetes = 48%

Type 2 Diabetes = 52%

Use Insulin = 73%

Reported A1c 6.5% and lower = 60%

Reported A1c higher than 8% = 23%

Major Findings

Type 1 Diabetes

Those in the lower A1c bracket (<6.5%) are significantly more likely than those with a higher A1c (>8%) to: Eat a very low-carbohydrate diet (<40 g per day): 22% vs. 7% Not vary their daily carbohydrate intake: 9% vs. 28% Use an insulin pump: 71% vs. 53% Wear a continuous glucose monitor (CGM): 76% vs. 60% Have lower “high glucose alert” setting on their CGM: <150 mg/dL: 28% vs. 9 % <120 mg/dL: 5% vs. 0% >200 mg/dL: 31% vs. 76% Have lower “low glucose alert” settings on their CGM: <80 mg/dL: 96% vs. 85% <70 mg/dL: 67% vs. 51% >90 mg/dL: 3% vs. 14% Not vary the timing of their meal-time insulin: 43% vs. 59% Incorporate the protein content of their meal in determining their bolus insulin dose: 44% vs. 23% Eat similar food every day, at similar times, AND limit eating out at restaurants: 20% vs. 7% Exercise: Daily: 21% vs. 11% 4-6 times per week: 24% vs. 8% Less than once per week: 40% vs. 66% Feel very confident about their diabetes management skills: 82% vs. 39% Feel very optimistic about their long-term health: 59% vs. 42% Feel that diabetes doesn’t greatly interfere with their daily life: 35% vs. 21% Report a high degree of socioemotional support related to diabetes: 68% vs. 56%



Type 2 Diabetes

Those in the lower A1c bracket (<6.5%) are significantly more likely than those with a higher A1c (>8%) to: Eat a very low-carbohydrate diet (<40 g per day): 32% vs. 13% Eat a ketogenic diet (<20 g per day): 13% vs. 0% Not vary their daily carbohydrate intake: 16% vs. 29% Eat a low-carbohydrate lunch (<20 g) on a regular basis: 50% vs. 28% Use an insulin pump: 10% vs. 3% Vary the timing of their meal-time insulin: 53% vs. 40% Exercise: Daily: 14% vs. 8% 4-6 times per week: 20% vs. 8% Less than once per week: 51% vs. 73% Feel very confident about their diabetes management skills: 69% vs. 26% Feel very optimistic about their long-term health: 58% vs. 30% Feel that diabetes doesn’t greatly interfere with their daily life: 56 vs. 19% Report a high degree of socioemotional support related to diabetes: 59% vs. 46%



Key Takeaways

Based on this survey data, the common diabetes management habits reported among patients with lower (<6.5%) A1c as compared to those with higher (>8%) A1cs are:

Type 1 and Type 2 Diabetes

Consume a lower-carbohydrate diet on a regular basis.

Use an insulin pump.

Exercise regularly.

Type 1 Diabetes

Use a continuous glucose monitor.

Eat similar food every day, at similar times, AND limit eating out at restaurants.

Incorporate the protein content of meals in calculating bolus insulin doses.

Read the full reports on these subjects here:

Habits of a Great A1c: Carbohydrate Intake

Are people who achieve optimal A1c levels more likely to eat fewer carbohydrates?

With the ever-increasing popularity and clinical acceptance of low-carbohydrate diets for the management of type 1 and type 2 diabetes, this was one big question on our mind as we designed the survey for our first-ever data-driven article.

To determine this, we asked survey participants to report both how many carbohydrates they typically consume per day, as well as approximately how many carbohydrates they typically consume for each meal. In general, participants selected the option that most closely represented their carbohydrate intake from the following:

Over 100 g (per day or per meal)

Between 80-100 g (per day or per meal)

Between 60-80 g (per day or per meal)

Between 40-60 g (per day or per meal)

Between 20-40 g (per day or per meal)

Under 20 g (per day or per meal)

Carbohydrate intake is too variable to select one option

After collecting the data, we compared the proportion of people eating at the various carbohydrate levels to determine the differences between those with a self-reported A1c of <6.5% as compared to those with a self-reported A1c of >8%.

Here are the results:

Carbohydrate Intake and A1c: Type 1 Diabetes

A total of 148 participants with type 1 diabetes who reported an A1c level of <6.5% and 60 who reported an A1c of >8% responded to survey questions about carbohydrate intake patterns. The reported carbohydrate intake was generally lower for those who reported optimal (<6.5%) A1c levels. The differences between the groups were statistically significant for a daily carbohydrate intake of fewer than 40 g per day.

Also, a statistically significant difference was found for variable carbohydrate intake, with those reported being more likely to vary their day-to-day carbohydrate intake, also reporting higher A1c levels.

The by-meal reported carbohydrate distribution also showed a similar trend, with a lower carbohydrate intake reported by people in the lower A1c bracket for most meals.

Carbohydrate Intake and A1c: Type 2 Diabetes

A total of 147 participants with type 2 diabetes who reported an A1c level of <6.5% and 72 who reported an A1c of >8% responded to survey questions about carbohydrate intake patterns. The data for type 2 diabetes closely followed the trend observed in the type 1 diabetes group, with a greater proportion of participants in the lower A1c bracket reporting lower carbohydrate intake.

Strikingly, while 13% in the lower A1c group (<6.5%) reported following a very low-carbohydrate/ketogenic diet (< 20g per day), no one in the higher A1c group (>8%) reported such a degree of carbohydrate restriction.

Discussion

A lower level of carbohydrate intake was associated with having a more optimal A1c level among patients with type 1 and type 2 diabetes in this survey study. In particular, a carbohydrate intake of fewer than 40 g per day was significantly more likely among those who reported achieving an A1c less than 6.5% vs. those who reported and A1c higher than 8%.

These findings are consistent with what we expected, as multiple research studies have previously revealed the benefits of carbohydrate restriction on glycemic management, in particular for patients with type 2 diabetes.

Of course, there are limitations to this survey investigation; most notably, all the data (including A1c and carbohydrate intake) are self-reported. However, these outcomes are in line with many scientific and anecdotal reports alike, and the sample size is robust for all analyses.

Also of note, there was a considerable proportion of people who ate >100g per day in the lower A1c group (~22% among the type 1 population and ~11% among the type 2 population), highlighting that it is certainly possible to achieve recommended A1c targets on a higher carbohydrate intake.

Further analysis into more detailed A1c brackets (e.g., <6.0%), as well as an analysis of insulin users vs. non-insulin users in the type 2 population, will be interesting to explore.

Check out the following articles to learn more about low-carbohydrate eating for diabetes:

ADA 2019: Low-Carb Diets for Type 1 Diabetes

ADA 2019: Low-Carb Diets for Type 2 Diabetes

How to Start a Low-Carb Diet

Ketogenic Diet

Habits of a Great A1c: Technology Use

How likely are those who report an A1c of <6.5% to use insulin pump or continuous glucose monitoring (CGM) technology vs. those with an A1c of >8%? Are there differences in the way these individuals make use of the technology?

We aimed to find out the connections between insulin pump and CGM use and self-reported A1c levels. Because very few individuals with type 2 diabetes reported using this technology in our survey, this article focuses on those with type 1 diabetes. Of note, although the sample size was small, people with type 2 diabetes in the lower reported A1c bracket were significantly more likely to use an insulin pump (~10% (n=11) in the <6.5% A1c group vs. ~3% (n=5) in the >8.0% A1c group).

Among those with type 1 diabetes, several hundred individuals reported on their technology use habits. In addition to collecting data on insulin pump and CGM use, we also asked participants detailed questions about their CGM alert settings.

Insulin Pump and CGM Use Among Patients with Type 1 Diabetes

We identified that a larger proportion of people in the <6.5% A1c bracket reported using insulin pump as well as CGM technology as compared to those with an A1c of >8%. Although more people in the lower A1c bracket reported using both devices concurrently, this metric did not reach statistical significance (35% vs. 29%).

Differences in CGM Alert Settings

Importantly, we found significant differences in the CGM alert setting reported by those in the optimal (<6.5%) A1c group vs. those with higher reported A1c levels (>8%) for both high and low blood glucose alerts. In general, people with a lower reported A1c were more likely to set their hyperglycemia alerts to lower levels. Strikingly, only 31% of those in the lowerA1c bracket reported setting their high alert to 200 mg/dL or higher, as compared to 76% of those who reported higher A1c levels.

Similarly, those with lower reported A1c levels were more likely to have their hypoglycemia alerts programmed to lower levels.

Discussion

Overall, these data suggest that people who achieve optimal A1c levels are more likely to make use of diabetes technology, including insulin pumps and CGMs. Moreover, the differences observed in the reported CGM settings indicate that those achieving optimal A1c levels tend to have more narrow target ranges, and presumably act to correct hyperglycemia faster, which may directly translate to the improved glycemic control.

Habits of a Great A1c: Exercise Patterns

We all know that exercise confers tremendous health benefits on everyone, and people with diabetes are no exception. So, we asked the question:

Are people who achieve optimal A1c levels more likely to engage in exercise on a regular basis?

Hundreds of survey participants with type 1 and type 2 diabetes responded to detailed questions about their exercise patterns. After collecting the data, we analyzed the differences in the proportion of people who engage in regular exercise among those who reported an A1c of <6.5% as compared to those with a reported A1c of >8%. Here is what we found:

Exercise Habits and A1c: Type 1 Diabetes

The survey results revealed that those with lower self-reported A1c levels were more likely to report exercising at least 4 times per week as compared to those with higher A1c levels among those with type 1 diabetes. Those with a higher A1c level were significantly more likely to report very low exercise frequencies (less than once per week). There were no significant differences in the proportion of people who reported exercising 1-3 times per week between the two A1c groups.

Exercise Habits and A1c: Type 2 Diabetes

Among patients with type 2 diabetes, a similar trend was observed as for those with type 1 diabetes. Those with lower self-reported A1c levels were more likely to report exercising at least 4 times per week as compared to those with higher A1c levels, while there were no significant differences in the proportion of people who reported exercising 1-3 times per week between the two groups. Those with a higher self-reported A1c level were significantly more likely to report very low exercise frequencies (less than once per week).

Discussion

Exercise is known to improve insulin sensitivity in healthy people, as well as in those with type 1 and type 2 diabetes. In fact, regular physical activity is a clinically-accepted strategy in improving the health of children and adults with diabetes, and has been demonstrated as effective in helping to optimize glycemic management. Our survey results are consistent with this knowledge, and underscore exercise as an important tenet of health for people with diabetes.

Although we cannot infer a causal relationship between exercise patterns and glycemic management in this analysis, it can be hypothesized that the association of regular exercise with more optimal diabetes control may be directly related, as improved glycemic control, likely as a direct result of improved insulin sensitivity, is well-documented in the scientific literature. As per the 2018 American Diabetes Association (ADA) consensus statement:

Children and adolescents with type 1 or type 2 diabetes or prediabetes should engage in 60 min/day or more of moderate- or vigorous-intensity aerobic activity, with vigorous muscle-strengthening and bone-strengthening activities at least 3 days/week. Clinical trials have provided strong evidence for the A1C-lowering value of resistance training in older adults with type 2 diabetes and for an additive benefit of combined aerobic and resistance exercise in adults with type 2 diabetes. If not contraindicated, patients with type 2 diabetes should be encouraged to do at least two weekly sessions of resistance exercise (exercise with free weights or weight machines), with each session consisting of at least one set (group of consecutive repetitive exercise motions) of five or more different resistance exercises involving the large muscle groups. For type 1 diabetes, although exercise in general is associated with improvement in disease status, care needs to be taken in titrating exercise with respect to glycemic management. Each individual with type 1 diabetes has a variable glycemic response to exercise. This variability should be taken into consideration when recommending the type and duration of exercise for a given individual. Women with preexisting diabetes, particularly type 2 diabetes, and those at risk for or presenting with gestational diabetes mellitus should be advised to engage in regular moderate physical activity prior to and during their pregnancies as tolerated.

It is important to consult with your healthcare team prior to beginning a new exercise program or changing your exercise habits. Blood glucose-lowering medications, like insulin, will likely need to be adjusted and hypoglycemia during exercise may be of particular concern for patients with type 1 diabetes.

Habits of a Great A1c: Meal Strategies

What food-related habits do those with an optimal A1c level have in common? We already analyzed carbohydrate intake and found those with lower reported A1c levels were more likely to eat a very low-carb diet, but what other food-related strategies do those with successful management often implement?

Here, we focused on analyzing three meal-related habits as they relate to A1c. We asked our survey participants which of the following strategies (if any) they implement to help manage their blood glucose levels:

Eating meals at the same time of the day Eating similar foods on a regular basis Limiting dining out

Next, we assessed if there were any significant differences in the proportion of individuals that implemented a particular habit or combination of habits between those who reported an A1c of <6.5% as compared to those with an A1c >8%.

Eating Habits and A1c: Type 1 Diabetes

A total of 252 patients with a self-reported A1c of <6.5% and 134 patients with a self-reported A1c of >8% answered questions about their meal planning habits among those with type 1 diabetes. Overall, there was a trend for those in the lower A1c bracket being more likely to report implementing some combinations of these habits.

Importantly, those with a lower self-reported A1c were significantly more likely to implement all three habits simultaneously, while those with a higher self-reported A1c were significantly more likely to not implement any of these strategies.

Eating Habits and A1c: Type 2 Diabetes

A total of 96 patients with a self-reported A1c of <6.5% and 128 patients with a self-reported A1c of >8% answered questions about their meal patterns among those with type 2 diabetes. While we did not find any statistically significant differences in these dietary habits in this patient population, considerably more people in the lower reported A1c bracket adhered to all three habits simultaneously as compared to those with a higher self-reported A1c (21% vs. 13%).

Discussion

It is particularly interesting that patients with a lower reported A1c level were more likely to implement all three dietary strategies to manage their blood glucose levels. While there were no significant differences for an individual habit between the two groups, the combination of all three habits was more prevalent among those reporting optimal A1c levels.

We believe this underscores the complex nature of successful diabetes management. There are a multitude of variables involved in optimizing glycemia and carefully understanding and addressing as many as possible is more likely to help improve management.

Habits of a Great A1c: Insulin Use Strategies

Do insulin use strategies differ significantly between patients who achieve optimal (<6.5%) A1c levels vs. those with higher (>8%) A1cs?

We aimed to find out as part of our first-ever data-driven journalism effort.

We asked hundreds of survey participants questions about the following basal and bolus insulin use habits:

Bolus insulin timing patterns

Administering insulin for protein

Timing of insulin corrections

Number of basal injections per 24 hrs.

There were no significant differences observed in the timing of insulin correction doses (a similar proportion of people in the low and high A1c brackets reported taking correction doses with insulin still on board) among patients with type 1 and type 2 diabetes. There were also no significant differences observed in the number of basal injections (single injection vs. two or more) per day among any groups.

Bolus Insulin Timing Patterns

More people in the lower (<6.5%) A1c bracket reported taking their insulin at least 5-10 minutes before eating (pre-bolus) as compared to those with higher reported A1cs among patients with type 1 diabetes (30% vs. 18%). Interestingly, we discovered that patients with type 1 diabetes in the higher (>8%) A1c bracket were significantly more likely to vary the timing of their bolus insulin between meals (59% vs. 43% in the lower A1c group). This result was somewhat surprising, as we initially hypothesized that varying insulin timing based on circumstances (meal composition, etc.) might be a useful habit to optimize glycemic control. However, it is also possible that the higher likelihood of varying bolus insulin timing observed among those with a higher A1c level is reflective of forgetting insulin boluses at or prior to the meal or snack, or indicative of nonchalance with respect to appropriate bolus timing.

Notably, we found the opposite trend among patients with type 2 diabetes. Those with lower reported A1c levels were significantly more likely to vary the timing of their bolus insulin doses (53% vs. 40% in the higher A1c bracket).

Administering Insulin for Protein

Although carbohydrate intake has the most pronounced effects on blood glucose levels, it is well-established that protein intake can also have an effect. While there was no association of this habit with A1c among those with type 2 diabetes, the differences among those with type 1 diabetes were striking: 44% of patients with optimal A1c levels reported incorporating protein intake in the bolus insulin calculation as compared to only 23% of those in the higher A1c bracket.

To learn more about dosing insulin for protein, check out this article.

Discussion

Overall, there was a trend of administering insulin for meals earlier and a significant tendency to consider the protein content of their meals in calculating insulin doses among patients with type 1 diabetes who reported lower (<6.5%) A1c levels as compared to those with higher (>8%) reported A1cs. These trends were not observed among the type 2 diabetes population in this survey study.

Also, there were differences in the likelihood of varying bolus insulin timing among patients with type 1 and type 2 diabetes among the different reported A1c brackets, underscoring the heterogeneity of these populations as related to insulin use patterns.

Habits of a Great A1c: Socioemotional Wellbeing

How important are emotional factors and social support when it comes to successful diabetes management?

We investigated socioemotional factors that could be related to diabetes management by asking hundreds of patients with type 1 and type 2 diabetes detailed questions about the following:

Diabetes management confidence

Optimism about long-term health

Interference of diabetes with daily life

Emotional support

The verdict: the patient-reported perceptions of these variables differed drastically between those who reported achieving a hemoglobin A1c level of <6.5% as compared to those with an A1c of >8%.

Socioemotional Factors and A1c in Patients with Type 1 Diabetes

Among patients with type 1 diabetes, those with a self-reported A1c level of <6.5% were significantly more likely to feel very confident about their diabetes management skills, and reported a higher level of optimism about their long-term health as compared to those with a reported A1c of >8%. Also, those in the lower A1c bracket were significantly more likely to report that diabetes seldom interferes with their daily life and were also more likely to report a high level of emotional support in their lives.

Socioemotional Factors and A1c in Patients with Type 2 Diabetes

The results among patients with type 2 diabetes were almost identical to the trends observed among those with type 1 diabetes. Patients in the lower reported A1c bracket were significantly more likely to report a higher degree of confidence in their diabetes management skills, optimism about long-term health, perceive diabetes to be less of a hassle on a daily basis, and receive a higher degree of emotional support.

Discussion

It makes sense that those with tighter diabetes control are more likely to feel confident and empowered about their health as it relates to diabetes. It is likely that these differences relate directly to diabetes management success, although it is also possible that those who tend to feel more confident and optimistic fare better in the rigorous tasks required for more optimal diabetes management.

It is not clear from this analysis whether a higher perceived level of emotional support has a direct influence on diabetes management. This is certainly possible; another possibility is those with more optimal control are more likely to seek out such support in person or online.

Notably, the trends in these socioemotional factors as they relate to the A1c level were very similar among people with type 1 and type 2 diabetes, unlike many other variables that we previously assessed.

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What do you think about these results? How do you view these factors as they relate to your diabetes management? Please share this data report and your thoughts in the comments below.

Also, check out a comprehensive glossary of diabetes-related terms and learn more about various diabetes concers, complicaitons, and available medical tests here.