Have you heard? At the 74th Scientific Sessions in June, the American Diabetes Association (ADA) released a new position statement that specifically addresses the needs of people with Type 1 across the lifespan. Previous guidelines largely regarded Type 1 as a pediatric disease, ignoring the fact that there is a growing population of people with Type 1 who are now living long enough to be navigating issues of aging. Acknowledging that those with Type 1 have different needs than those with Type 2 (T2) diabetes, the new position statement fills a void in the past guidelines. Types 1 and 2 are different disease processes and they are treated and managed differently. The new guidelines also mesh with those of ISPAD, the International Society for Pediatric and Adolescent Diabetes.
In an effort to keep the message both simple and consistent, the authors wanted to harmonize the guidelines with those of other national and international diabetes organizations. They emphasized that they have a commitment to separating out the two different types of diabetes.
The new ADA position statement recommends that Type 1 (T1) children under the age of 19 should aim for an A1c level under 7.5%. Fear of hypoglycemia and the complications that it can cause drove the old targets, which called for an A1c not to exceed 8.5% in children under age 6, 8.0% ages 6-12, and 7.5% for adolescents.
Today we have better tools to monitor and prevent hypoglycemia, and research shows that chronically high BG (blood glucose) can lead to the development of complications such as cardiovascular disease and kidney disease in childhood. These are not complications that only occur in adults, as was once believed. We are still concerned about hypoglycemia, but this is balanced by evidence showing a higher risk of harm stemming from prolonged hyperglycemia. The new recommendation is evidence-based. Still, the authors of the position statement stressed that both BG and A1c goals need to be individualized.
On the other side of the lifespan, the new A1c targets are higher for older adults. Since adulthood spans from age 18 to 100 and beyond, it is vital to understand the circumstances of the individual adult patient, especially for older adults with significant complications from longstanding T1 diabetes. The guideline states, “…it is important to assess the clinical needs of the patient, setting specific goals and expectations that may differ significantly between a healthy 26-year-old and a frail 84-year-old with (cardiovascular disease and retinopathy).” The A1c goal for adults is <7.0%. For a healthy older adult, the goal is <7.5%. For an older adult with complex or intermediate health issues, the goal is <8.0%. For those with complex health problems or who are in poor health, the goal is <8.5%.
In further elaboration of the goals for adults, the position statement says, “The benefits of interventions such as stringent glycemic control may not apply to those with advanced complications of diabetes or to those with a life expectancy of less than the anticipated time frame of benefit. Conversely, the risks of interventions such as tight glycemic control (hypoglycemia, treatment burden) may be greater in older adults. Although individualism is critical, in general, older patients with long life expectancy and little comorbidity should have treatment targets similar to those of middle-aged or younger adults.”
Most of the summaries of the new guidelines that I read online emphasized the changes on the pediatric side, but provided little detail about the recommendations for adults. I found it much more informative to go directly to the 21 page original source in order to learn the particulars for adults.
All in all, I have a very positive view of the Position Statement. I was happy to see the ADA pay particular attention to the needs of the T1 community, as I often hear criticism that the ADA is focused on T2. As diabetes educators, we have a strong mandate to individualize recommendations for each patient. I think these new guidelines urge us to continue to do just that, while acknowledging that needs do change throughout the lifespan.
It is sometimes a struggle for older adults to acknowledge that there is a need to re-adjust expectations due to changing health and functional status. I’m really curious to see how this will unfold on the pediatric side. Many parents are extremely fearful of hypoglycemia. When people “graze” constantly and are in a perpetual “fed” state for most of their waking hours, BGs will run above target range for most of the day. After all, we expect that after-meal BGs will be higher than pre-meal values. I’m hoping that this guideline will also help the public to realize that this is a balancing act, and we need to do a cost-benefit analysis in order to keep people as safe and healthy as possible.
At Integrated Diabetes Services, we consider the day-to-day BG values, BG variability, and the amount of time spent in the target BG range to be better than A1c as indicators of the quality of one’s diabetes management. We always try to set goals collaboratively with our clients. It takes work (and assumption of some risk) to get the A1c down, and everyone’s wants/needs/desires are a little different. A1c is an important number, but I sometimes think that clinicians put too much emphasis on the A1c and lose sight of the fact that there’s a lot to be said for stability. An at-goal A1c that is achieved via frequent highs and lows is still not what we would call desirable.