India is estimated to have 10.13 crore people with diabetes, and another 13.6 crore people who are pre-diabetic, according to a nationwide study published in 2023. This apart, over 35% of Indians suffer from hypertension and nearly 40% from abdominal obesity, both of which are risk factors for diabetes. India accounts for 17% of all diabetes patients in the world.

Prevention and early detection are key to helping combat this non-communicable disease burden, experts say. One of the most commonly-used tests to diagnose pre-diabetes and diabetes (both type 1 and type 2) and to help manage diabetes, is the haemoglobin A1C (HbA1C) test, also known as the glycated haemoglobin or glycosylated haemoglobin test.

How does the test work?

Sugar enters your bloodstream from the food you eat. The sugar, or glucose, attaches to the haemoglobin in your red blood cells. Haemoglobin is a protein that transports oxygen to all the cells of your body.

Everybody has some sugar attached to their haemoglobin. Those with pre-diabetes and diabetes, however, have more. The HbA1C test measures the percentage of your red blood cells that have sugar-coated, or glycated, haemoglobin.

Why is the test used to check for diabetes?

A paper was published in the Cleveland Clinic Journal of Medicine in 2016 entitled ‘The role of haemoglobin A1c in the assessment of diabetes and cardiovascular risk’. It stated: “HbA1c was first discovered in 1955, but elevated HbA1c levels in diabetes patients were not noted until 1968. Another eight years passed before HbA1c was correlated with blood glucose values in hospitalised patients with diabetes and was proposed for monitoring glycemia.”

During the first few years of clinical use, the paper said, HbA1c measures were inconsistent. But as the importance of precise HbA1c measurements became apparent through studies that revealed better patient outcomes and mortality associated with lower average HbA1c, the need to reduce error margins in measurement became apparent.

Following programmes to regulate HBA1c measurements and calibrate them to reference standards, standardisation and accuracy greatly improved from 1993 to 2012, the paper noted.

The American Diabetes Association approved HbA1c as a diagnostic tool in 2009. In 2011, after an expert consultation with the World Health Organisation (WHO), it said HbA1c could be used as a diagnostic test for diabetes “provided … stringent quality assurance tests are in place and assays are standardised to criteria aligned to the international reference values, and there are no conditions present which preclude its accurate measurement.”

What do HbA1C test results look like?

The HbA1C levels are provided as either a percentage or in mmol/mol (which stands for millimoles per mole). A mole is a unit of measurement often used for chemical substances.

The higher the percentage, the higher your blood glucose levels are. An Hb1A1C below 5.7% is considered normal; between 5.7 and 6.4% may indicate you are pre-diabetic; and 6.5% or higher can indicate diabetes. In mmol/mol: below 42 corresponds to below 6.0%; 42-47 mmol/mol to 6.0 to 6.4%; and 48 mmol/mol to 6.5% or over.

However, the test’s results may change under certain conditions, including if a patient has kidney or liver failure, severe anaemia or a blood disorder such as thalassemia; if they have a less common type of haemoglobin found in some populations; or are under certain medications including steroids, opiates or dapsone (a drug used to treat leprosy). They may even change if a person is in early or late pregnancy.

Generally, for those whose results indicate pre-diabetes or diabetes, doctors specify a goal to achieve specific HbA1C levels. But these vary from person to person and also depend on their age, health conditions, medications being taken, and other factors.

Who needs to take the test and when?

According to the Indian Council of Medical Research’s Guidelines for Management of Type 2 Diabetes (2018), all individuals older than 30 years should be screened for diabetes. Those with one or more risk factors including, among others, obesity, an increased waist circumference, a history of or being treated for hypertension, a history of heart disease, and a history of polycystic ovarian syndrome should be screened earlier.

Retests should be conducted after three years in case of normal glucose tolerance. If a person is pre-diabetic, retests should be annual. Your doctor may also ask you to be tested more frequently if, for instance, you’re planning to have a baby.

If you have diabetes, your doctor may ask you to take it every three to six months, to keep an eye on your blood sugar levels and to check if your treatment plan is working.

How does the test differ from others?

While fasting and post-prandial or post-meal blood sugar tests give you blood sugar levels within a specific time frame, the HbA1C test reflects your average blood glucose levels over the last two to three months.

Also, while the traditional blood sugar tests may fluctuate depending on items in the person’s latest meal and when they last consumed it, the HbA1C test is independent of these variables, making it more reliable. It can be taken irrespective of when the latest meal was consumed.

What are the test’s limitations?

It is important to note the HbA1C test does not replace other tests and may be carried out alongside others, such as the traditional blood sugar tests to test for diabetes and pre-diabetes. It also does not replace regular blood-sugar testing at home, which a doctor may have recommended, as the blood sugar levels may spike and dip through the day or night, and the HbA1C test may not capture this.

This apart, while the HbA1C test remains one of the best to assess long-term control of diabetes in people known to have diabetes, it is not uniformly accepted as a diagnostic test by all global medical bodies because of its relatively low sensitivity arising from difficulties in assay standardisation. In other words, a doctor may recommend a glucose test alongside an HbA1C test to obtain a clearer picture when diagnosing a person.

The test may also have limitations particular in India. A 2013 paper published in the journal Diabetes Technology and Therapeutics noted that in some clinical situations, accurate measurements are harder to make. These include having conditions like thalassaemia, structural haemoglobin variants in the population, iron-deficiency anaemia (which is relatively high in India), and the use of certain drugs.

“Because of the relatively frequent occurrence of some of these conditions in some parts of India, it is important that they are looked for when evaluating an inappropriately high or low HbA1c level. Alternative indices may have to be used for assessing glycemic control in these cases,” the paper noted.

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