Glycomate

What is HbA1c?

When you talk about diabetes control the most common term you will hear in the management and control of diabetes is the HbA1c. Also known as glycated haemoglobin or A1c. The HbA1c is not the average glucose but reflects the average glucose for the previous 90 days.


What is HbA1c?

The goal is to understand:

  • The HbA1c and its importance in reflecting diabetes control and complications.

  • What is the target HbA1c for you?


Everybody, including those without diabetes, has an HbA1c (usually less than 6%). The HbA1c develops when haemoglobin, a protein within red blood cells that carries oxygen throughout your body, after being exposed to glucose in the blood, joins with this glucose becoming 'glycated'. From this you can see that the more glucose in the blood the more glycated haemoglobin, hence the more HbA1c that is measured.


The HbA1c (the amount of haemoglobin that is glycated) is usually expressed as a percentage of the total haemoglobin (1). New measures report the A1c as a single number (mmol per mol) (2). For example, a HbA1c of 7%, is reported also as 53 mmol per mol and tells us that the average blood glucose level (BGL) is 8.6 mmol with a range of 6.8 to 10.3. See Table 1.


By measuring this HbA1c, doctors are able to get an overall picture of what the average blood glucose (some will use the term sugar) levels have been over a period of 90 days. It is well documented that the higher the HbA1c, the greater the risk of developing diabetes-related complications. For people with diabetes this is important.


Why is the HbA1c important?


The HbA1C assay is accepted as the most reliable means of assessing blood glucose control (3–5). Many studies have established the association between risk for long-term complications and high HbA1c. These same studies have shown that even a 0.9% reduction in HbA1c is rewarded with 20-40% reduction in complications (6-8). This reduced complication rate has led to the establishment of specific A1C targets for well controlled diabetes with the goal of preventing or delaying the development of long-term complications such as eye disease and vision loss, strokes, heart attacks, kidney disease, neuropathy and amputations (3, 9 –11).


Well controlled diabetes is associated with low risk of complication and events and is associated with good health, energy, vibrancy and well-being. Poorly controlled diabetes is associated with increased risk for events (we call these complications) reduced energy, poorer outcomes, less well-being.


The HbA1c is the indicator of control and it can reflect quality of life. Some people have called it a quality of life number. The lower the A1c, the lower your risk of complications. The higher your A1c, the higher your risk of complications (6-8).


How does HbA1c translate to Average Blood Glucose?


First, there is a very predictable relationship between HbA1c and average glucose. Understanding this relationship can help people with diabetes and their health-care providers set day-to-day targets for average glucose based on HbA1c goals. Second, the A1c Derived Average Glucose (ADAG) study has allowed mathematical conversion of HbA1c to an estimated average glucose and also conversion of average glucose to an estimated or predicted HbA1c. In this manner, when a person with diabetes does self-monitoring by testing their blood glucose for a few days, the average can be used to predict a HbA1c.


Further, this average can be used to check concordance with the blood sample HbA1c done at the pathologist. When there is no concordance, further discussion between the doctor and patient must take place to find an explanation.


Thirdly, fasting glucose should be used with caution as a surrogate measure of the average blood glucose because post meal increases are not captured on the fasting measurement but are reflected in the HbA1c.


Post meal (or postprandial) blood glucose is the predominant contributor to HbA1c in people satisfactory to good control of diabetes, whereas the contribution of fasting blood glucose increases with worsening diabetes. Post meal thresholds for predicting good or satisfactory control of diabetes are dependent on the timing of the meals (12).


Table 1: Estimated Average Glucose (13-14)

Estimated Average Glucose

What is the target HbA1c for you to live with well controlled diabetes?

If you have diabetes, the recommended HbA1c is less than 7%, and a tighter goal of 6.5% may be appropriate for some people (e.g. newly diagnosed and very young). These thresholds are further individualised according to age, duration of diabetes, life expectancy, complications (15).


So, what should your target be? International studies have concluded that age and presence of end organ damage are factors we should consider when determining personal targets (16). The Australian Diabetes Society also takes into consideration duration of diabetes, medications and hypoglycaemia events.


TARGET HbA1c AS A PERCENTAGE – DIABETES DURATION < 10 years

Hba1c target less than 10 years

TARGET HbA1c AS A PERCENTAGE – DIABETES DURATION > 10 years

Hba1c target greater than 10 years

Understanding A1c In a Nutshell

  • The HbA1c is important in assessing control of diabetes.

  • The HbA1c is not the average blood glucose, but reflects the average.

  • The HbA1c tells you where you are with respect to your BGL control NOT how you got there. The self-measuring of BGL (the testing you do at home) tells you how you achieved the HbA1c.

  • The higher the HbA1c the poorer the control, the more the complications the less wellness.

  • The general target is to have a HbA1c of less than 7% but this needs to be individualised.


Do you know your HbA1c value?


If you have diabetes you need to understand the HbA1c and know your HbA1c value. Know your numbers. Find out if you are living with well controlled diabetes.





REFERENCES

  1. http://www.ngsp.org/A1ceAG.asp

  2. 2. Jeppsson JO, Kobold U, Barr J, Finke A, Hoelzel W, Hoshino T, Miedema K, Mosca A, Mauri P, Paroni R, Thienpont L, Umemoto M, Weykamp C: Approved IFCC reference method for the measurement of HbA1c in human blood. Clin Chem Lab Med 40:78–89, 2002 https://www.ncbi.nlm.nih.gov/pubmed/11916276.

  3. Saudek CD, Derr RL, Kalvani RR: Assessing glycaemia in diabetes using self-monitoring blood glucose and hemoglobin A1c. JAMA 295:1688–1697, 2006 https://www.ncbi.nlm.nih.gov/pubmed/16609091.

  4. American Diabetes Association: Standards of medical care of diabetes. Diabetes Care 30 (Suppl. 1):S4–S41, 2007 https://www.ncbi.nlm.nih.gov/pubmed/17192377.

  5. Goldstein DE, Little R, Lorenz RA, Malone JI, Nathan DM, Peterson CM, Sacks DB: Tests of glycaemia in diabetes. Diabetes Care 27:1761–1773, 2004 https://www.ncbi.nlm.nih.gov/pubmed/15220264.

  6. Diabetes Control and Complications Trial Research Group: The effect of intensive diabetes treatment on the development and progression of long-term complications in insulin-dependent diabetes mellitus: Diabetes Control and Complications Trial. N Engl J Med 329:978–986, 1993 https://www.ncbi.nlm.nih.gov/pubmed/8366922.

  7. DCCT Research Group: The association between glycaemic exposure and long-term diabetic complications in the Diabetes Control and Complications Trial. Diabetes 44:968–983, 1995 https://www.ncbi.nlm.nih.gov/pubmed/7622004.

  8. UK Prospective Diabetes Study Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352:837–853, 1988 https://www.ncbi.nlm.nih.gov/pubmed/9742976.

  9. European Diabetes Policy Group: A desk-top guide to type 2 diabetes mellitus. Diabet Med 16:716–730, 1999 https://www.ncbi.nlm.nih.gov/pubmed/10510947.

  10. Nathan DM, Buse JB, Davidson MB, Heine RJ, Holman RR, Sherwin R, Zinman B: Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy. Diabetes Care 29:1963–1972, 2006 https://www.ncbi.nlm.nih.gov/pubmed/16873813.

  11. Glycemic Targets: Standards of Medical Care in Diabetes 2019. American Diabetes Association. Diabetes Care 2019 Jan; 42(Supplement 1): S61-S70.https://doi.org/10.2337/dc19-S006.

  12. Contributions of fasting and postprandial glucose to hemoglobin A1c. Monnier L1, Colette C.

  13. Nathan DM, Kuenen J, Borg R, Zheng H, Schoenfeld D, Heine RJ. A1c-Derived Average Glucose Study Group. Translating the A1C assay into estimated average glucose values. Diabetes Care. 2008;31:1473-1478. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742903/ https://www.ncbi.nlm.nih.gov/pubmed/18540046.

  14. http://www.ngsp.org/ifccngsp.asp

  15. Individualizing Glycemic Targets in Type 2 Diabetes Mellitus: Implications of Recent Clinical Trials. Faramarz Ismail-Beigi, MD, PhD; Etie Moghissi, MD; Margaret Tiktin, NP; Irl B. Hirsch, MD; Silvio E. Inzucchi, MD; and Saul Genuth, MD.

  16. Algorithms for personalized therapy of type 2 diabetes: results of a web-based international survey. Marco Gallo1, Edoardo Mannucci2, Salvatore De Cosmo3, Sandro Gentile4, Riccardo Candido5, Alberto De Micheli6, Antonino Di Benedetto7, Katherine Esposito4, Stefano Genovese8, Gerardo Medea9, Antonio Ceriello10,11 on behalf of Associazione Medici Diabetologi (AMD).


Dr. Chrys Michaelides