When the ground-breaking Diabetes Control and Complications Trial, or “DCCT,” results were reported in 1993, for the first time, specific goals for glycemic control in patients with diabetes were recommended by the ADA; the DCCT had shown conclusively that intensive treatment of type 1 diabetes that resulted in lower average plasma glucose levels, was associated with striking reductions in risks for the development and progression of diabetes complications. The treatment goals were based on hemoglobin A1c testing (HbA1c) and were as follows: for most people with diabetes, the goal should be for HbA1c <7% and that levels over 8% “required action.” Since the DCCT studied only people with type 1 diabetes between the ages of 13-39 years, the ADA suggested caution in extrapolating the DCCT test results to people younger and older that the 13-39 age range and for people with type 2 diabetes. For children, the recommended HbA1c goals were as follows: 7.5-8.5% for children under age 6 years; < 8.0% for children ages 6-12 years of age; and < 7.5 for adolescents. The stated reason for the less stringent goals in children was because of concern for brain damage from hypoglycemia, and data suggesting that risks for the development of diabetes chronic complications did not start until puberty.
As I recall, at the time many pediatric endocrinologists did not agree with the HbA1c guidelines for children; as far as I know, they simply ignored them, aiming for the best possible glycemic control in all patients with diabetes, while working hard to minimize risks for hypoglycemia. This approach to diabetes care has long since been proven to be far better than the approach recommended by the ADA in 1993. Finally, this summer, the ADA announced at the 74th Scientific Sessions held in San Francisco in June that the HbA1c targets for children had been revised. The new goals are as follows: HbA1c < 7.5% for all children less than 19 years of age. One reason for the new goals was to “harmonize” the ADA HbA1c guidelines for children with diabetes with the International Society for Pediatric and Adolescent Diabetes (ISPAD). I applaud the ADA’s decision, but I wish guidelines had been changed many years ago. But, as I mentioned above, I think few pediatric endocrinologists paid any attention to them. Of course, that raises the question of whether medical treatment guidelines published by national and international organizations are worth much. I’m not going there.
Finally, I confess that I still like the original ADA HbA1c guidelines which included an “action needed” level. I have heard it said that if a patient has a HbA1c > 8% it reflects either laboratory error or hemoglobinopathy, a patient who is not following a good treatment plan, or a compliant patient who is following a poorly conceived treatment plan. I can’t say that I disagree.
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