We are living in an era where the prevalence of diabetes continues to be on the rise. This disease affects nearly 25.8 million, or 1 in 12, Americans.1 While the number of diagnosed cases is steadily increasing, the time that doctors have to spend with their patients is becoming very limited, especially at a time where there is a dearth of primary care physicians.2 Many patients are turning instead to a pharmacist who they know and trust to provide a more in-depth explanation of their disease states and medications. This unique situation provides pharmacists with the opportunity to showcase our skills and the value that we add to healthcare through patient education, motivational support, and follow-up counseling.3 Pharmacists can also go a step further and become a Certified Diabetes Educator specializing in diabetes management, prediabetes, and diabetes prevention.
While many patients understand the importance of monitoring their blood glucose levels, they lack the connection that an A1C reading has to diabetes. Most patients recognize the name of the test, but less than 50% of patients with diabetes know their A1C level or what their target level is.4 It is vital that patients with diabetes understand what the A1C test means, why this test is important to them, and how to manage their lifestyle and medications to work toward a lower A1C level. Conveying these key concepts to patients at a level that they will understand can be tricky. However, when patients understand the concepts involving their disease states and how it impacts them, they can be more proactive in their care.5
In simple terms, the A1C test conveys to the healthcare provider what percentage of hemoglobin, an iron-containing and oxygen-carrying protein found in red blood cells, is attached to a glucose molecule. When a patient’s blood sugar is high, this allows for more glucose molecules to attach to the blood’s hemoglobin. Red blood cells have an average life cycle of 120 days, and new cells are constantly being created. It is key to point out to the patient that the continuous generation of new blood cells allows for them to achieve different A1C results every few months. This shows them that their diabetic medications and lifestyle choices can make a difference. In patients with diabetes, a higher percentage of coated hemoglobin results in an increase in the patient’s A1C level, which has a strong predictive value for increased complications such as cardiovascular disease, nephropathy, retinopathy, and is indicative of poor control of blood glucose levels. Therefore, maintaining the patient’s A1C close to normal levels should allow for less risks and lower costs of care in the long run.6
The A1C test requires routine blood draws that will occur based on how well the patient’s blood sugar levels are controlled. Patients should expect that their doctor may request to see them quarterly to monitor their progress if they have had a change in therapy or their blood sugar is not well controlled. Taking measurements every 3 months provides a clearer picture to the doctor about whether glycemic goals have been maintained. Once the patient is meeting treatment goals and has stable glycemic control, the A1C test may only need to be performed twice a year. When consulting your patient, make sure that they have a follow-up appointment scheduled with their physician.
As pharmacists, we can make sure that the patient understands why this examination is important to them so that they follow through with their care. A typical patient with diabetes will test their blood sugar at certain points of the day, which provides their physician with a very limited picture. The A1C test allows the physician to see an average of a patient’s blood glucose over a 3-month period. The American Diabetes Association describes an A1C reading as being similar to a baseball player’s seasonal batting average. This measurement displays the overall success of the patient in controlling their glycemic levels, not a single game’s batting record or a single day’s blood glucose readings.6
Next, it is vital that the patient understands what their A1C number represents. Not knowing your A1C is like driving a car at night with no headlights on a dimly lit road. Clearly, your chances of crashing are high. The normal level for A1C in a patient that does not have diabetes is between 4% and 6%. An A1C of 6% corresponds to an estimated average glucose of 126 mg/dL.6,7 The goals for glycemic control will vary between patients and are at the physician’s discretion. The A1C target is dynamic and can change for a patient based on their age, comorbid conditions, duration of diabetes, risk for hypoglycemia, and life expectancy. Patients need to understand that once their goal is decided, it will take time to achieve it and should not be rushed. An A1C target of less than 6.5% is still considered optimal according to the “2013 AACE Comprehensive Diabetes Management Algorithm” released by the American Association of Clinical Endocrinologists, but only if that goal can be achieved in a safe manner that avoids hypoglycemia.7,8
Lastly, as pharmacists, we can reinforce that medication adherence and changes in lifestyle, such as dietary modifications and increased physical activity, can significantly impact a patient’s A1C levels. Controlling a patient’s A1C requires a lot of skill. The medication regimen needs to be balanced with their diet choices, physical activity, weight, and daily stress levels. Diabetics do not possess enough insulin to push the excess sugar molecules toward their cells and so it builds up in the blood. When a patient indulges in excessive carbohydrates, this can cause their A1C levels to rise because carbohydrates are broken down into sugar. Stress also can cause an accumulation in the blood by sending a message to the liver to produce more sugar. Excess weight requires more insulin to provide sugar to the muscles and the brain and can result in insulin resistance.5
To counteract their diabetes, it is recommended that patients participate in moderate exercise starting at least 3 times a week for 30 minutes and then building up to 5 days a week. This may include a brisk walk, cycling, or swimming.7 Controlling their diet using the “Plate Method” is a great start toward glycemic control.9 The Plate Method involves using a 9-inch plate and reserving half of the plate for vegetables (they can keep this empty for breakfast), 1 quarter of the plate for lean meat or proteins, and the last quarter of the plate for starches or grains. They can also indulge in 8 ounces of low-fat milk and a half cup of fruit with each meal. Meat and proteins may include beef, chicken, salmon, eggs, and cottage cheese. Starches or carbohydrates may include oatmeal, dry cereals, whole grains, and whole wheat pasta. Lastly, nonstarchy vegetables such as broccoli, lettuce, carrots, artichokes, cucumbers, celery, and salsa are recommended. Following the Plate Method for 3 meals a day and adding up to 2 nutritious snacks will help put the patient on the right track to reaching their glycemic goals.9 Over-the-counter supplements such as cinnamon, chromium, and zinc may have value in lowering glucose levels as well. Patients should always discuss using these supplements with their doctor first though before beginning use. Avoiding alcohol consumption should also be addressed as well as the use of medications that can cause an increase in blood glucose levels, such as steroids and atypical antipsychotics.
Conclusion
Patients with diabetes can face potentially serious health concerns. As pharmacists, we can have a positive impact at the patient level through our regular contact with this population. Before you end your A1C conversation with a patient, always be sure to have them recap what you discussed. This will allow you to judge their level of understanding. This also provides the patient with the opportunity to voice any concerns that they may have. In the end, improving patients’ understanding of diabetes management is the key to establishing better health outcomes.
References
- Centers for Disease Control and Prevention. National Diabetes Fact Sheet: National Estimates and General Information on Diabetes and Prediabetes in the United States, 2011. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2011.
- Dugdale DC, Epstein R, Pantilat SZ. Time and the patient–physician relationship. J Gen Intern Med. 1999;14(Suppl 1):S34-S40.
- Fera T, Bluml BM, Ellis WM. Diabetes Ten City Challenge: final economic and clinical results. J Am Pharm Assoc. 2009;49(3):383-391.
- Harwell TS, Dettori N, McDowall JM, et al. Do persons with diabetes know their (A1C) number? Diabetes Educ. 2002;28(1):99-105.
- Utah Department of Health. Utah Diabetes Practice Recommendations–Patient Advisory. Utah Department of Health. Salt Lake City, UT: Utah Department of Health; 2006. http://health.utah.gov/diabetes/pdf/udpr/udpr_a1cpatientadvisory_nov06.pdf. Accessed September 10, 2013.
- American Diabetes Association. Living with Diabetes: A1C and eAG. Published July 30, 2013. http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glu cose-control/a1c/. Accessed September 10, 2013.
- American Diabetes Association. Standards of Medical Care in Diabetes—2013. Diabetes Care. 2013;36:S11-S66.
- Garber A, Abrahamson M, Barzilay J, et al. AACE Comprehensive Diabetes Management Algorithm 2013. Endocr Pract. 2013;19:328-335. https://www.aace.com/files/aace_algorithm.pdf. Accessed September 10, 2013.
- McCulloch M. Plate Method Meal Ideas. Diabetic Living. 2013. http://www.diabeticlivingonline.com/food-to-eat/nutrition/plate-method-meal-ideas. Accessed September 10, 2013.
