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Pediatric HbA1c levels in 2010: Goals vs. what is being achieved
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The American Diabetes Association and other organizations have established target glycemic goals for children to encourage physicians and families to achieve blood glucose and HbA1c levels in a range that will decrease the risk for long-term microvascular and macrovascular risks for hyperglycemia while avoiding excessive episodes of severe hypoglycemia.
Current ADA recommendations are graduated, with somewhat higher HbA1c targets for younger children (7.5% to 8.5% in children aged younger than 6 years) and progressively lower target values as children progress in age (less than 8% in children aged 6 to 13 years and less than 7.5% in those aged 13 to 18 years). This is designed to minimize the risk for hypoglycemia in children who may be at an increased risk for severe hypoglycemia because they are too young to recognize the symptoms of hypoglycemia and/or independently seek attention for prompt treatment of mild or moderate hypoglycemia.
Other organizations, such as the International Society for Pediatric and Adolescent Diabetes (ISPAD), have recommended a single glycemic goal — HbA1c of less than 7.5% — for all children younger than 18 years.
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All organizations recommend that goals should be individualized, with higher goals for children with hypoglycemia unawareness or frequent episodes of severe hypoglycemia, and lower goals for children who can achieve these goals without frequent hypoglycemia.
Glycemic control in studies
The Diabetes Control and Complications Trial (DCCT) and Epidemiology of Diabetes Interventions and Complications have shown that providing new, more advanced technologies; additional education in diabetes management; and professional attention and motivation within a research setting can significantly decrease HbA1c levels. However, technology alone, without additional professional attention, is insufficient to achieve the same degree of sustained glycemic improvement. In addition, within the DCCT, the adolescent cohorts could not achieve the same degree of control as the adult cohorts. Indeed, they were only able to achieve an HbA1c that was approximately 1% higher than that achieved by the adult cohorts, demonstrating the increased difficulty of adolescents to accomplish the same degree of glycemic control as adults within the same treatment program.
The HbA1c results in children with type 1 diabetes in multicenter epidemiology studies in Europe and the United States confirm that children, particularly adolescents, are not meeting current glycemic targets.
The most recent Hvidore Study Group report of 2,100 children with type 1 diabetes and a mean diabetes duration of 6.1 years found that only one of 21 diabetes centers had a mean HbA1c within the ISPAD target of less than 7.5%, with an overall mean HbA1c for all participating centers of 8.2%.
In the United States, the SEARCH for Diabetes in Youth Study found a mean HbA1c of 8.3% in 2,999 youth with a mean diabetes duration of 5 years, with only 44% of participants meeting their ADA glycemic goal for age. SEARCH publications further document that HbA1c is associated with unalterable socioeconomic factors, frequency of self-blood glucose testing, insulin regimen and mode of administration with more intensive diabetes management associated with a lower HbA1c value, even when adjusted for socioeconomic factors. However, it is possible that this is a self-selected group, in which only those who are willing and able to comply with the intensive treatment regimen are assigned to that treatment and, thus, are the ones who are more likely to do better with their diabetes self-management.
Technology to improve goals
Because more intensive management can improve diabetes control and early reports of continuous glucose monitoring (CGM) technology in children were positive, pediatric endocrinologists have been hopeful that patients will benefit from this new technology. Unfortunately, larger studies have demonstrated that although there are those who can use this technology consistently, many adolescents are unable to wear the CGM device over a sustained period of time. Those who were able to wear the devices 6 or more days per week for 6 months showed a significant decrease in their HbA1c levels; but, in a research study setting, only 30% of 14- to 24-year-olds were able to wear the sensor 6 days or more per week. In a setting designed to mimic a “real world” clinical setting, only 19% of this age group was able to wear the sensor as recommended, and 21% were not able to wear the sensor at all by the last 6 months of the trial.
These reports document that better sensors, which are more comfortable and more convenient, are needed, and diabetes care providers must have a better understanding of how to motivate young people to accept new diabetes technology and to use it in a way that optimizes their current and future health. New technology in glucose sensing, perhaps leading to a glucose-driven, feedback-controlled insulin delivery system, appears to be able to dramatically improve glycemic levels without increasing the risk for hypoglycemia. However, unless young people can use this technology, they will not reap the rewards of this advanced diabetes management system.
Georgeanna Klingensmith, MD, is chief of pediatric clinical care at the Barbara Davis Center for Childhood Diabetes and is professor of pediatrics at the University of Colorado, Denver.
For more information:
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