I was one of the many pwd who was stunned back in 2015 when the UK’s National Institute for Clinical Excellence (NICE) issued its Guidelines for Type 1 Diabetes in Adults. These guidelines recommended a “target” HBA1c of less than 6.5%. The previous target was 7.5%
What I found stunning was that so few people managed to achieve an a1c of 7.5% or less and yet here they were setting an even lower target. For the record -the UK National Diabetes Audit showed that 29% of adults with type 1 recorded an a1c <7.5% (or 58mmol in the new measure) in 2015/16 AND fewer than one in fifteen (i.e. less than 10% of pwd) recorded an a1c of less than 6.5%.
It makes you wonder what exactly is the point of setting this number, what does it mean and is it sensible to set a target that appears cannot be achieved by 90% of people.
Study after study shows that very few type 1s record an a1c of less than 6.5% but according to some people, setting the target that low will encourage us to do better than we otherwise might. What seems to be missing in the communication around A1c targets is that the target is, apparently, “aspirational”.
The target is the “hole in one”- it’s what we aim for and we get as close as we can: provide skills/tools 2 get as close as they can
and later he elaborates on the aspirational target idea
This approach is taking us a long way from the scientific, evidence base of the a1c and into grey areas of motivational psychology.
The thing about setting targets is that if they are too difficult to achieve then performance is likely to suffer because many people are so discouraged by a target that appears out of reach is that they just give up-(the business world has lots of research on the psychology of targets-they’re usually called budgets).
Diabetes is forever and frankly, “failing” to reach a target every 3 months for the rest of your life is going to have a detrimental impact on many people’s sense of self-efficacy and potentially their mental health.
So what to do?
Let’s acknowledge that the lower your a1c the less risk you have for complications but that is not the only measure of a life well lived with type 1 diabetes. Let’s also acknowledge that the target a1cs, be they 7.5 or 6.5% are REALLY tough to achieve and therefore stop beating ourselves up if we “miss the mark”. Let’s look for practical ways to improve your a1c, I’ve said before if you’re at the Dr’s office ask for 1 implementable suggestion that will help get your a1c down & give it a go.
Unusually, I’m going to give the last word on this to another UK endocrinologist, Dr Partha Kar, who commented on the NICE target as follows
I am saying no one should be judged by ability to hit a target- which appears to be nigh impossible to get to as per % achievements
Amen to that!
How do you view the A1c? How has it been presented to you by HCPs? Do orgs etc? Please let me know in the comments