Last year, when the American Diabetes Association (ADA) updated its annual “Standards of Medical Care in Diabetes” document—the set of recommendations that largely guides diabetes care in America—the organization made a significant change that wasn’t much remarked upon at the time. The listed HbA1c target for children with Type 1 diabetes was changed from <7.5% to <7.0%.
This is the lowest A1c target that the organization has ever recommended for children since it began recommending age-specific targets in 2005.
The ADA’s decision to tighten A1c targets for children—which mirrors similar decisions made by other organizations in other nations—is a clear expression that improving glucose control in our children is both possible and worth doing. It’s good news. Most of the news we’ve heard in recent years about diabetes outcomes in America has been bad (Diabetes Technology is Better, So Why are Outcomes Worse?), so we are pleased to see the country’s most important diabetes organization begin to push for at least some improvement.
Glycemic control has always been an especially thorny issue in children and teens. On the one hand, children are just beginning decades of life with Type 1 diabetes, which usually means a future of decades of accumulated health damages. Youngsters, therefore, would probably benefit more than anyone from reductions in the severity and duration of chronic hyperglycemia. On the other hand, they’re still kids, and don’t necessarily have the focus and discipline that fastidious glycemic management demands. Parents have to make those decisions for them, at least for a while, juggling social and behavioral issues along with medical ones. And even among the more independent set, it’s the rare child or teen that has the maturity to properly weigh short-term feelings of pleasure (or belonging or normalcy) against negative short- and long-term health impacts. Heck, it’s the rare adult that can do it.
In the latest edition of Diabetes Care, the ADA’s medical journal, members of the organization’s Professional Practice Committee wrote to detail the new evidence that drove the recommendation.
In the first place, the evidence that childhood hyperglycemia causes major health damages is just getting stronger all the time. In an interview with Medical Xpress, lead author Dr. Maria Redondo stated that, “Until recently, there was a mistaken belief that sugar fluctuations in pre-pubescent children do not cause any long-term harm. However, it is increasingly evident that is not true.”
The article lays out an alarming list of negative health outcomes associated with acute and chronic blood sugar highs in childhood. The evidence is described as “overwhelming.”
High blood sugar:
- Causes neurocognitive dysfunction and structural brain changes in children
- Increases the likelihood of both micro- and macrovascular diabetes complications
- Makes it more difficult to achieve good control later in life (so-called “metabolic memory”)
- Increases the risk of early death
To put it simply, high blood sugar is incredibly unhealthy at any age. Kids don’t get a pass.
As always, the factor to balance against the danger of hyperglycemia is the danger of hypoglycemia—low blood sugar. If there is a single surpassing reason that children were recommended looser glycemic control over the past fifteen years, it was the threat of hypoglycemia. This has been the fear at least since the landmark DCCT study, which both conclusively demonstrated the dangers of chronic high blood sugars and showed that lower A1c’s led to a greater frequency of hypoglycemic events. The fear still informs much mainstream diabetes advice. If you’re like me, you’ve already had an endocrinologist or diabetes educator tell you that a low A1c would be cause for concern for this very reason.
While there’s no reason to stop taking hypoglycemia seriously, the Diabetes Care article also reviews reasons to believe that the association between low A1c and hypoglycemia risk is not nearly as strong as commonly supposed, and has weakened over the years. Rates of hypoglycemia have declined significantly since the days of the DCCT, which after all was conducted mostly in the 1980s, several generations of glucose and insulin technology ago, at a time when “intensive glucose control” was considered experimental. A lot has changed since then. The bottom line is that hypos just don’t happen nearly as often as they used to. We have much better technology than we used to, better insulin, and better understanding too. As continuous glucose monitors and closed-loop pump systems become more popular, the association between low A1c and hypo risk should get even weaker in the future.
The guidance still allows that higher glycemic targets of 7.5% or even 8.0% may be suitable for children with significant other issues, including hypoglycemia unawareness, severe comorbidities or short life expectancy. By the same token, newly diagnosed patients enjoying the “honeymoon” period might use stricter a stricter target of 6.5%.