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ADA Changes Pediatric A1c Recommendations

By Judith C. Thalheimer, RD, LDN

In July, the American Diabetes Association (ADA) released an important new position statement called “Type 1 Diabetes Through the Life Span.” These guidelines are the first clinical practice recommendations focused exclusively on type 1 diabetes across the entire age spectrum. The expert review involved in creating the guidelines led to a dramatic change in the ADA’s recommendation for A1c goals for children and adolescents.

The ADA previously had recommended A1c goals of <8.5% for children under 6, <8% for those aged 6 to 12, and <7.5% for teens aged 13 to 19. The new recommendation calls for an A1c goal of <7.5% across all pediatric age groups.

Rationale for Previous Guidelines
“The previous treatment guidelines for pediatric patients were derived in an era in which severe hypoglycemia was a serious concern, especially in very young children who could not recognize or articulate symptoms,” explains Lori Laffel, MD, MPH, one of the authors of the position statement. Early studies indicated that young children who had repeated hypoglycemia episodes with seizure and/or coma could develop neurocognitive problems.1 Moreover, it was thought that high blood sugar levels before puberty had little impact on the development of long-term diabetes complications such as vision loss, kidney failure, nerve damage, and heart disease. Therefore, the consensus at the time was that recommendations allowing higher average blood sugar levels in young children would help protect neurocognitive development without risk of long-term consequences.

New Research Supports Change
“Newer treatments using modern insulin analogs reduce risk for hypoglycemia,” Laffel says. “In addition, review of the previous evidence concerning neurocognitive issues related to low blood sugar was questionable. Now there are imaging studies indicating that high blood sugar may adversely impact the developing brain.” High blood sugar in children also may increase risk of long-term diabetes complications. Many investigators and clinicians now believe it’s important to control blood glucose and A1c levels before puberty to reduce the risk of both micro- and macrovascular complications. “Insulin analogs and new technologies that improve blood sugar control, along with the knowledge that we can lower A1c without causing severe hypoglycemia coupled with the preliminary evidence that high blood sugar may be related to neurocognitive problems all led to the reassessment of the previous recommendations,” Laffel says. The new ADA recommendation for the A1c goal of <7.5% across the entire pediatric age range is in agreement with the International Society of Pediatric and Adolescent Diabetes, the Pediatric Endocrine Society, and the International Diabetes Federation. “We feel that patients can safely reach for this goal, so the time is right to harmonize with other organizations,” Laffel says.

Importance of Individualization
Nevertheless, the ADA does emphasize that blood sugar targets always should be individualized to maximize health outcomes, minimize the risk of hypo- and hyperglycemia, and maintain normal growth and development. “The fundamental approach to diabetes management is always the delivery of individualized care by a multidisciplinary team,” Laffel says. “We must take into account factors such as patient needs, family needs, and cultural preferences when creating a treatment program and setting A1c targets. Goals need to be realistic and timely.”

Heidi Quinn, MS, RD, LDN, pediatric nutrition educator with the pediatric, adolescent, and young adult section of the Joslin Diabetes Center, cautions against putting too much emphasis on meeting A1c goals alone. “When we talk to patients about A1c goals, the emphasis is on checking blood glucose levels and correcting them in efforts to get to goal,” Quinn says. “Sometimes it’s difficult to predict when blood glucose is going to go high. Sometimes it’s related to foods eaten but it could also be related to a competitive sports situation, the stress of an upcoming exam, or coming down with a cold or other illness. There are just times when blood sugars are going to be high, but they can be corrected. Our motto is ‘check and fix.’” Not all patients will be ready to reach for the new lower goal right away. Change can be incremental. “If a patient has an A1c of 10%,” Laffel says, “the goal is to achieve an A1c less than 10%.”

Counseling Tips
The new guidelines may change the goalpost, but they don’t change the goal. “The recommended A1c level may be different, but the nutrition recommendations for kids with type 1 diabetes are the same,” Quinn says. “The bottom line is to promote overall healthful eating as you would for any child. We follow the standard Institute of Medicine Dietary Reference Intake recommendations for children, encouraging a healthful diet with a balance of protein, fat, and healthful, quality carbohydrates like whole grains, fruits, vegetables, beans, and low-fat dairy.”

The new ADA recommendations for all pediatric age groups to achieve an A1c goal of <7.5% represents a response to improved medications and technologies and advancing scientific research. Dietitians can use A1c goals to encourage clients and patients to work harder at blood sugar control, but should always work with them to set realistic and reasonable individual goals. “None of us has a magic wand that changes behavior,” Laffel says. “Our job is to motivate patients and families today to come close to their goals tomorrow.”

— Judith C. Thalheimer, RD, LDN, is a freelance nutrition writer, a community educator, and the principal of JTRD Nutrition Education Services.

Reference
1. Rovet JF, Ehrlich RM. The effect of hypoglycemic seizures on cognitive function in children with diabetes: a 7-year prospective study. J Pediatr. 1999;134:503-506.