My previous blog discussed the new American Diabetes Association (ADA) guidelines regarding hemoglobin (hb) A1c for people younger than 18 years old with diabetes (less than 7.5 percent) and over 18 years of age (less than 7.0 percent). For those over 18 years, consideration of other illnesses and chronic conditions must be included. I have received many comments and questions in both the comments section of my previous blog as well as from my own pediatric diabetes practice, and the consensus is mixed.
First of all, to quote the actual statement, which is in bold: "While A1c and blood glucose targets are needed, the ADA emphasizes that glycemic targets should be individualized with the goal of achieving the best possible control while minimizing the risk of severe hyperglycemia and hypoglycemia." They continue to state, "more or less stringent glycemic goals may be appropriate for individual patients." (Chiang, Kirkman, Laffel, and Peters, on behalf of the Type 1 Diabetes Sourcebook Authors, Type 1 Diabetes Through the Life Span: A Position Statement of the American Diabetes Association, Diabetes Care 2014; 37:2034-2054: DOI: 10.2337/dc14-1140)
Therefore, where do these statements leave us? As I previously mentioned, my initial concern was that we are asking already stressed individuals who are currently working extremely diligently to manage their blood sugars to work harder. Will this lead to further frustration, depression, and "diabetes burnout?" Will physicians change their current treatment plans to achieve these more stringent guidelines? Will patients with diabetes actually change their behaviors to further lower their A1c?
Adult commentary ranged from outrage to the actual possibility of "loosening" control in order to reach the A1c suggestion of 7.0 percent! This was a suggestion from a healthcare provider to an older patient with outstanding control in association with minimal hypoglycaemia. Of course, my response to the comment was to recommend staying the course, and that if the current treatment regimen was actually working successfully without consequences, there was no need to make any substantive changes.
As far as from my own patient practice, comments ranged from, "I can't believe they are making me further lower my A1c below 8.0” and “I might as well just give up," to "I guess they are putting teeth into the fact that there are less microvascular and macrovascular complications with lower A1c values." For most parents of younger children, there was more or less a tacit understanding that they were already doing the best they can and could not do any further treatment to lower A1c without increasing the risk of significant hypoglycemia. Further education in regard to research demonstrating lack of cognitive consequences in young people with hypoglycemia was very reassuring to most parents.
In my view, after further reflection, the key to all of these statements is perspective. One must look at the whole picture and pay most attention to the fact that yes, indeed, glycemic targets should, I would go even further to say must, be individualized. The collective “they” are basing recommendations on evidence-based literature and are in effect, setting the guideposts but not suggesting that everyone must adhere exactly to these recommendations. I would prefer to think that these are guidelines that people with diabetes need to know and, in many cases, to aspire. However, if one has an A1c of 7.6 percent, it does not mean that the 15-year-old adolescent has failed. An author of this study relayed a comment to me that resonated personally: “It is important to manage expectations.”
The question is: whose expectations are we managing?
I answer: first and foremost, the person with diabetes, the caregivers, and the healthcare team. After careful consideration of all these varying expectations, along with the understanding that expectations may be variable during different stages of life, one can only then determine what may be best for the person with diabetes, using the new ADA position statement as guidelines.
Published On: September 29, 2014