Sugar Mountain: Why it's Difficult to Lower Very High A1Cs
As is my usual practice, many of my ideas for blogs originate with my experiences with patients and families. Using analogies in clinical practice in order to make concepts more understandable is an excellent means to reach an “aha” moment. Oftentimes, we, as clinicians, provide very comprehensive explanations as to why certain biologic phenomena occur in a detailed manner. Although patients and families may understand the general concepts, the messages are not internalized, and thus, behavior is not altered significantly.
The title “Sugar Mountain” was coined by the mother of one of my patients several weeks ago after I was attempting to explain why it is often difficult to lower very high hb A1cs.
Medical version: A very high hb A1c may reflect average blood sugars in very high ranges over 300. When a patient has had high hb A1cs for many months or years, he or she oftentimes become accustomed to high blood sugars, and a blood sugar level of 300 may feel normal. Therefore, as we attempt to lower hb A1cs with tighter control, a blood sugar that is in the mid-100 levels may feel low to the patient, and he or she may treat the assumed low level with rapid-acting carbohydrates based on how their body is reacting (if they don’t check blood sugar). Even if the patient does check their blood sugar, and it is in the normal range, they may still feel low and treat anyway.
Most people say they totally get this explanation, but I have yet to see that “aha” moment. Therefore, I began to try a different approach:
Mountain climbing version: As mountaineers ascend Mount Everest, they need to stop at base camps at various altitudes in order to acclimate to the lower atmospheric oxygen pressure. The climb, therefore, requires multiple stops for extended periods to continue the ascent safely. In this sense, we can compare this acclimation to lower hb A1cs and lower blood sugars in a similar manner, except in our real-life case we are descending the “mountain.” As the blood sugars become lower, the person with diabetes must acclimate to the normalizing blood sugar in order to feel euglycemic and not low. It will require additional blood glucose monitoring to ensure an adjustment to normal blood sugars instead of relying just on feel. On first use, this explanation evoked an “aha” moment for my patient. Her mother called it the “Sugar Mountain” approach. I will continue to try to use this approach on other patients to help them understand the process.
I would also appreciate any other explanatory analogies. Please send comments my way.
American Diabetes Association Update:
The American Diabetes Association (ADA) has recently posted new guidelines on suggested hb A1c levels in children, adolescents, and adults. They have now recommended that hb A1c be less than seven point five percent for all age groups, including young children. I was at a meeting when these recommendations were revealed and asked the presenter as to the logic of providing a much lower target for young children. My concern was that it would make it more frustrating for parents of young children to reach the target level and may cause further anxiety for both the children and parents. The presenter indicated that he initially responded in a similar manner, but that this was just a guideline, and of course should be adjusted for each individual. Another apt question presented was that if we aim for a hb A1c of eight and reach it, should we settle? The answer, of course, is no. I will now provide the new guidelines for all patients. However, it is important to decide the appropriate A1c goal for each individual child or adolescent with diabetes based on their age after consulting with the family and child.
My goal has always been to have the lowest possible A1c without significant hypoglycemia.