Variability in the Relationship of Hemoglobin A1c and Average Glucose Concentrations: How Much Does Race Matter?

Editorials18 July 2017Variability in the Relationship of Hemoglobin A1c and Average Glucose Concentrations: How Much Does Race Matter?Elizabeth Selvin, PhD, MPH and David B. Sacks, MBChBElizabeth Selvin, PhD, MPHFrom Johns Hopkins Bloomberg School of Public Health, Baltimore, and National Institutes of Health, Bethesda, Maryland.Search for more papers by this author and David B. Sacks, MBChBFrom Johns Hopkins Bloomberg School of Public Health, Baltimore, and National Institutes of Health, Bethesda, Maryland.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M17-1231 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The recommendation to use hemoglobin A1c (HbA1c) for diagnosis of diabetes, first made in 2009, was controversial. One source of contention has been the interpretation of racial differences in HbA1c and whether nonglycemic factors contribute to the higher levels seen in black persons than in white persons. Data documenting this difference in the United States date back to at least the early 1980s, and much of the difference has been thought to relate to disparities in risk factors, glycemic control, access to care, and socioeconomic status.The well-designed and carefully conducted study by Bergenstal and colleagues (1) contributes to our ...References1. Bergenstal RM, Gal RL, Connor CG, Gubitosi-Klug R, Kruger D, Olson BA, et al; T1D Exchange Racial Difference Study Group. Racial differences in the relationship of glucose concentrations and hemoglobin A1c levels. Ann Intern Med. 2017;167:95-102. doi:10.7326/M16-2596 LinkGoogle Scholar2. 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;31:1473-8. [PMID: 18540046] doi:10.2337/dc08-0545 CrossrefMedlineGoogle Scholar3. Cengiz E, Tamborlane WV. A tale of two compartments: interstitial versus blood glucose monitoring. Diabetes Technol Ther. 2009;11 Suppl 1:S11-6. [PMID: 19469670] doi:10.1089/dia.2009.0002 CrossrefMedlineGoogle Scholar4. Beutler E, West C. Hematologic differences between African-Americans and whites: the roles of iron deficiency and alpha-thalassemia on hemoglobin levels and mean corpuscular volume. Blood. 2005;106:740-5. [PMID: 15790781] CrossrefMedlineGoogle Scholar5. Tarim O, Küçükerdogan A, Günay U, Eralp O, Ercan I. Effects of iron deficiency anemia on hemoglobin A1c in type 1 diabetes mellitus. Pediatr Int. 1999;41:357-62. [PMID: 10453183] CrossrefMedlineGoogle Scholar6. Welsh KJ, Kirkman MS, Sacks DB. Role of glycated proteins in the diagnosis and management of diabetes: research gaps and future directions. Diabetes Care. 2016;39:1299-306. [PMID: 27457632] doi:10.2337/dc15-2727 CrossrefMedlineGoogle Scholar7. Dagogo-Jack S. Pitfalls in the use of HbA1(c) as a diagnostic test: the ethnic conundrum. Nat Rev Endocrinol. 2010;6:589-93. [PMID: 20680035] doi:10.1038/nrendo.2010.126 CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: From Johns Hopkins Bloomberg School of Public Health, Baltimore, and National Institutes of Health, Bethesda, Maryland.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-1231.Corresponding Author: Elizabeth Selvin, PhD, MPH, Welch Center for Prevention, Epidemiology and Clinical Research and the Johns Hopkins Bloomberg School of Public Health, 2024 East Monument Street, Suite 2-600, Baltimore, MD 21287; e-mail, [email protected]edu.Current Author Addresses: Dr. Selvin: Welch Center for Prevention, Epidemiology and Clinical Research and the Johns Hopkins Bloomberg School of Public Health, 2024 East Monument Street, Suite 2-600, Baltimore, MD 21287.Dr. Sacks: National Institutes of Health, Building 10, Room 2C306, 10 Center Drive, Bethesda, MD 20892.This article was published at Annals.org on 13 June 2017. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoRacial Differences in the Relationship of Glucose Concentrations and Hemoglobin A1c Levels Richard M. Bergenstal , Robin L. Gal , Crystal G. Connor , Rose Gubitosi-Klug , Davida Kruger , Beth A. Olson , Steven M. Willi , Grazia Aleppo , Ruth S. Weinstock , Jamie Wood , Michael Rickels , Linda A. DiMeglio , Kathleen E. Bethin , Santica Marcovina , Andreana Tassopoulos , Sooji Lee , Elaine Massaro , Suzan Bzdick , Brian Ichihara , Eileen Markmann , Paul McGuigan , Stephanie Woerner , Michelle Ecker , Roy W. Beck , and Metrics Cited byAssociation of Baseline Characteristics With Insulin Sensitivity and β-Cell Function in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness (GRADE) Study CohortThe Sickle Effect: The Silent Titan Affecting Glycated Hemoglobin ReliabilityRetinopathy develops at similar glucose levels but higher HbA 1c levels in people with black African ancestry compared to white European ancestry: evidence for the need to individualize HbA 1c interpretationImplications of the Hemoglobin Glycation Index on the Diagnosis of Prediabetes and DiabetesHemoglobinopathies and Hemoglobin A1c in Diabetes MellitusThe National Glycohemoglobin Standardization Program: Over 20 Years of Improving Hemoglobin A1c MeasurementEvaluation of agreement between hemoglobin A1c, fasting glucose, and fructosamine in Senegalese individuals with and without sickle-cell traitSickle-cell trait and diagnosis of type 2 diabetesRacial disparity in HbA1c persists when fructosamine is used as a surrogate for mean blood glucose in youth with type 1 diabetesAssociation of Race and Ethnicity With Glycemic Control and Hemoglobin A 1c Levels in Youth With Type 1 Diabetes 18 July 2017Volume 167, Issue 2Page: 131-132KeywordsAttentionClinical epidemiologyGlucoseGlycationHbA1cHemoglobinPopulation statisticsPrevention, policy, and public healthRacial and ethnic issuesType 1 diabetes ePublished: 13 June 2017 Issue Published: 18 July 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. 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