Do you dread that moment during your child’s three-month checkup when it’s time to get your A1C “report card”? It’s understandable that many parents see the A1C result — which represents a child’s average blood glucose level since the last appointment — as a judgment on their ability to care for their child’s type 1 diabetes. So what’s really going on in your doctor’s mind when he or she delivers your child’s quarterly number? We asked some doctors for their perspective on this standard part of the diabetes appointment, and they had some interesting things to say about it.
Even a “Good” Number Doesn’t Tell the Whole Story
“Endocrinologists are incredibly invested in how their patients are doing, and when we see a hemoglobin A1C value that is moving higher, what we’re thinking is, ‘How can we do this better?’ A1C is an evaluation of our plan, so when I look at the results, I want to know: How much did A1C change since our last visit? Where does A1C need to be? What changes does our plan require? And in making changes going forward, it’s not just about reaching the destination of our goal A1C — it’s how we get there. What might surprise parents is that even when their child’s A1C is below 7, we’re still going to analyze this value and evaluate our plan to make sure this result reflects in-range numbers and not too many lows bringing it down. That’s too high a price to pay for a ‘good’ hemoglobin A1C.”
—Bradley Eilerman, M.D., staff endocrinologist at St. Elizabeth Physicians Regional Diabetes Center in Covington, Ky.
There’s Only One Thing That Truly Frustrates Us
“Sometimes patients come in and say, ‘You’re going to be so mad at me!’ because they know they’ve had a rocky past three months. But I never am. There are so many things that can happen over a three-month span in a child’s life, and your endocrinologist is aware of this. For example, when parents come in with their kids in early August after summer vacation, it’s not going to surprise me to see that A1C has edged higher since our last appointment. The family might have gone on a vacation over the summer or had a different schedule that affected management. A1C is looking at the past, not the present, and I know that when the school routine starts up again, this kid’s A1C is probably going to be fine. Other times, I will want to know more about the past three months, especially if A1C is consistently above where we want to be or has risen unexpectedly. I will ask about habits: Are fingers sticks going okay? Do care tasks feel socially awkward to carry out? We can work through any issues that come up, and I am glad to do so! The ONLY time there may ever be any sense of frustration is when a parent shows indifference to what we go over in the appointment and demonstrates that they are just not invested in following through. So for parents who are feeling worried about their child’s A1C, you really don’t need to be so hard on yourself, because it actually shows how much you care.”
The Prediction Is Almost More Important than the Result
“My goal in the appointment is to build a relationship with the child and learn more about how he or she is generally dealing with day-to-day life. I speak to the child first — regardless of age — and then the parents. I try to find out if the child is compliant with nutrition, exercise, and diabetes management and feels empowered and is staying on top of their diabetes. If the child is depressed or there are other challenges, we work on strategies for overcoming these issues. After our conversation, I am usually able to predict what the child’s A1C will be with about 90 percent accuracy. Only near the end of the visit after examining the blood sugars together do we look at the A1C result. It is always the very last thing we go over during the appointment. I know both the child and his or her parents worry about A1C and often feel somehow judged by it, but this result really is just another piece of information in the child’s overall care. What comes first for me is understanding as much as I can about the child and the family’s life.”
—Desmond Schatz, M.D., president of medicine and science for the American Diabetes Association and associate chairman of pediatrics and director of the Clinical Research Center at the University of Florida.
It’s Not Really Why You’re There
“After a child has been living with diabetes for some time, often the first thing parents want to know when they come in for the appointment is, ‘What’s my child’s A1C?’ The results are not ready until the end of the checkup, but even if they were, I want us to first focus on the day-in/day-out management of the child’s diabetes. We look over the meter log and discuss any changes since the last appointment — like pubertal growth, which can have a big impact on blood sugars and, as a result, A1C. Only after this lengthy conversation do we take a look at A1C results. Most of the time, A1C matches up with what we’ve talked about. If the A1C is a bit of a surprise, then I go back to ask more questions and see what we may have missed. What’s going through my head is that I want parents to feel like our discussion of A1C is more of a footnote to the appointment — and not the only reason why they are there. It really is a small part of a much larger conversation.”
—Anat Hanono, M.D., pediatric endocrinologist at the Joslin Diabetes Center in Boston, Mass.
The Everyday Is as Important as the Big Picture
“A1C is only one measure of a patient’s blood sugar control. While I do use it to look at overall control over the past three months, I consider the patient’s overall health as a whole and do not solely rely on the A1C value. In very young children, I look for recent growth spurts and dietary changes and really like to look at pump and glucometer downloads over the last two to four weeks to discuss changes with the family, because these children change so quickly. In school-age kids where things might be more leveled off, A1C might be a more steady measure, but I still discuss activity, growth, and dosing with meals to ensure that everyday issues are addressed in addition to the overall picture. In teenagers, I try to start pushing more awareness and improved A1C control BUT try not to treat it as a ‘grade’ or reflection of being ‘good’ or ‘bad’ as this can cause a strained relationship between the physician and teen. Also, while A1C is important for long-term outcomes, there are several factors that can artificially lower A1C — such as frequent hypoglycemia and skipping meals — that need to be addressed individually outside of just looking at A1C.”
—Amy Burton, M.D., medical staff board-certified in pediatrics and pediatric endocrinology at Texas Health Plano in Plano, Texas.
We Expect Less-Than-Perfect Numbers
“Children are constantly growing and changing, especially during puberty, and it’s normal that these different phases can cause blood sugar to fluctuate. It’s unrealistic to think that children will have ‘perfect’ blood sugar management — and ‘perfect’ A1C levels — all of the time. This is why bringing in your child’s day-to-day blood sugar logbook is so important — to paint the fullest picture possible of the last three months. If the A1C is not within its expected range, we can look back to see what challenges your child may have faced and what we can do to accommodate for them the next time these same issues come up.”
—Naznin M. Dixit, M.D., professor and chief of pediatric endocrinology and diabetes at the University of Mississippi Medical Center and Batson Children’s Hospital in Jackson, Miss.
Disclaimer: The experiences and suggestions recounted in these articles are not intended as medical advice, and they are not necessarily the “typical” experiences of families with a child who has type 1 diabetes. These situations are unique to the families depicted. Families should check with their healthcare professionals regarding the treatment of type 1 diabetes and the frequency of blood glucose monitoring.