The curse of comparing

Ever since numbers crept into the management of diabetes, all of us have fallen prey to our desire to compare and contrast. Searching for differences and variances in any situation are simply part of being a human being. That would not be much of a problem if we didn’t take the next step: to judge. Whether it’s the A1C, BG meter readings or sensor patterns, our ability to compare and contrast can easily slide down a dark path to judgment, shaming, and even condemnation. Social media allows for easier expression of these emotions.

I’ve shared hemoglobin A1C data with tens of thousands of patients and families over the last 35 years. At first, the value was not well understood or appreciated. But over time it became the centerpiece of the entire diabetes clinic visit and where it remains now for most persons with diabetes and/or their parents.

Why do we dwell so much on this number? In part because we’ve been taught that it can estimate the long term risk for certain problems associated with diabetes. These problems are scary to most of us and we fear that we (or our children with diabetes) might develop them some day if we don’t change our act. The medical system is also designed to use this information to instruct (‘program’ might be a better word) us on the consequences of our actions.

I find it paradoxical that I had NO A1C checks as a child. My first A1C as an adult at age 25 was over 10% after 15 years of diabetes. My parents did not have to carry that burden of numbers. A fact that I am actually thankful for.

The method of assessing diabetes control was based on colors. A urine dipstick or the color of a solution boiled in a test tube provided a rough estimate of the amount of sugar spilling over into my urine.

In pediatrics, parents are the most concerned about the A1C results. The tension in the room can be palpable when I’m about to share this information with them from our ‘point of care’ A1C device. Once the result is revealed there are several common responses that follow.

One is casual. Maybe even a bit nonchalant. This measured response could be from understanding that this number is just part of striving to live life well with diabetes. In other words, the A1C is not the “end all and be all”, just one piece of the puzzle of control.

In most cases the parent asks what the prior result was and promptly proclaims a specific judgment statement such as “I was afraid of that”, or looks at the child/teen and says “You went up” (never mind the “up” might be only a tenth of a point from the prior result). The statement might even be accompanied by a direct stare at the child or teen. It’s the visual version of “I told you so”.

Some never seem satisfied with any result they receive. A value of 6.3% might be “too high” based on their experience during the honeymoon when the values might have declined to values in the 5% range. There may be an excuse or two offered (these are not needed of course but flow freely) about an illness last week…or some problem that arose a couple of months back. I remind them that the A1C is not impacted by a few days of illness, but reflects changes over MONTHS of time.

It’s almost as if the parent is seeking absolution for the A1C result. I emphasize there is information within the reading, but NEVER any condemnation. An A1C is just a glycemic reflection of the past 3 months. Nothing more, nothing less.

I find it important to immediately discuss not using judgmental terms when discussing diabetes data. I often find I am in a small group of doctors who do this. Some of my professional brethren are well known to lay on heavy doses of judgment and condemnation for this number. Some have been known to even yell at their patients. Really?

But for the record, I advise anyone who has read this far to make a conscious effort to NOT use judgment terms when discussing BG data or an A1C result. These are numbers and the emotional emphasis that comes by prefacing these data with the words “good” or “bad” only serves to equate morality with physiology. These two forces are and should always be kept separate.