The American Diabetes Association and the World Health Organization, as well as a number of European and International groups have now finally agreed on the number needed to diagnose diabetes. Last summer they agreed that you can now use HgbA1c values to diagnose diabetes, now they agreed on the actual value.
Glucose tolerance tests and fasting glucose measures have long been the standard tests for screening and diagnosis of diabetes mellitus since 1997. In July 2009, the American Diabetes Association, the European Association for the Study of Diabetes, and the International Diabetes Federation Expert Committee published a consensus report recommending that hemoglobin A1c be used for the diagnosis of type 2 diabetes in nonpregnant individuals.
They have agreed that a HgbA1c of 6.5% or higher is DIAGNOSTIC of diabetes. And people who are 5.7-6.4% are "at risk" and should be watched closely. These are the new official guidelines. 6.5% = diabetes.
Surprisingly, a HgbA1c of 6.0% equals an estimated fasting glucose of 126 mg/dL which is diagnostic of diabetes. So, shouldn't 6.0% be used as the cutoff point? The American Diabetes Association has a nice conversion calculator on their website that has been verified and validated by tons of research. Try the calculator for yourself: http://professional.diabetes.org/GlucoseCalculator.aspx
What level A1c should you use?
Personally I think that a HgbA1c of 5.5% should be diagnostic of diabetes. That is equivalent to a fasting of 111. A HgbA1c of 6.5% is equivalent to a fasting glucose of 140, which is way too high and too late. Astute physicians have already been aggressive about blood sugars for anyone with a fasting over 100 or close to 100. No one's fasting glucose should be over 100 or close to it.
When they met, they argued and battled for a while. Some were arguing for 5.5% or even 5.1% to be the cutoff, since 5.1% equals a fasting of 100. But they were afraid that too many patients would now be considered "diabetic" that were unaware that they were diabetic before and would go into denial.
Why should we wait till 6.5%? Why not be more aggressive and start metformin and lifestyle modifications early. Why wait another 10-15 years before they are "completely" diabetic and already have kidney, nerve, and retina damage, and their pancreas is no longer salvageable? We should start them on metformin earlier and salvage some pancreas and other organs.
Why is HgbA1c better?
HgbA1c gives you a 90-120 day average of the patient's blood sugars. It is not affected by peaks and troughs. It is a stable average. It's nice to know what the patient's sugars have been running for the past 3 months, as opposed a one time reading.
It is more stable than fasting or random glucose. It doesn't change over time. When blood sits around in a laboratory for a few hours the glucose level can drop by as much as 10 mg/dL. If we use the cutoff of a fasting sugar of 126 to be diagnostic of diabetes, that can easily be missed or can delay diagnosis. So someone with a fasting sugar of 135 can be read as 125, and not be called "diabetic" and go on destorying their kidneys, nerves, and retinas with elevated glucose levels.
Additional advantages of HbA1c are that you don't have to fast prior to measurement, and the current clinical use of HbA1c results in daily management of patients with diabetes.
Caution:
People who have recently received a blood transfusion or carry the traits for Hgb C or S can have an erroneously low HgbA1c and you will need another test to confirm diabetes. To get a 2-3 week average on a sickler or pregnant patient, you can get a fructosamine test.
Pregnant patients (and people under any other high stress states: steroids, trauma, heart attack) unmask insulin resisitance (diabetes) for a short period of time. So you need a test like fructosamine which gives you a 2-3 week average to figure out how well their blood sugars have been controlled.
Insulin resistance is type 2 diabetes, certain states unmask it. The sooner you unmask it and catch it, the sooner you can start treating it. A pregnant patient that "became" diabetic during pregnancy, will always be diabetic. Don't fool yourselves. You either have diabetes (insulin resistance) or you don't. You are either born with it or you aren't. Certain states unmask it earlier than it would normally be caught. Be thankful we catch it early and can start treatment.
My thoughts:
FINALLY! But, I would use 5.5% or higher and be more aggressive. A HgbA1c of 5.5% equals a fasting glucose of 111. That is diabetic! Your fasting glucose should not be over 100!
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