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September 16, 2002

A1c (Glycohemoglobin, HgbA1c)

Question from Norfolk, Nebraska, USA:

My seven year old son, diagnosed two months ago, was never hospitalized with his type 1 diabetes, and we keep hearing that we are lucky we "caught it early" before he was very sick. At diagnosis, his A1c was 9.1%, and we have heard from other parents, grandparents and diabetes educators, that is a "wonderful A1c" to have at diagnosis, but I am confused by what this means. Is it in fact a "good A1c" compared to usual diagnosis A1cs? Since diagnosis, we have managed somewhat good control of his blood sugars. He is in a honeymoon and currently only receives a morning shot of NPH with Humalog. What should we expect for his first three-month A1c since diagnosis? What is a good A1c goal for someone his age?

Answer:

It would be inappropriate to set too much store on the exact level of a single initial hemoglobin A1c level. In the first place, there is likely to be a potential for error of at least plus or minus 0.5%, and, in addition, different laboratories may use different procedures and so have different normal ranges. With the two most common methods, normal levels should be less than 6.2%.

You are probably aware too that the autoimmune damage to the islet cells usually takes place over some years and that A1c levels reflect a mean blood sugar over the previous three months. This means that the A1c will be a little higher if the final step to insulin dependence is a gradual one rather than precipitated at an earlier stage by some intercurrent stress like a viral infection. The initial test is in any case a confirmation of long standing glucose intolerance and is not of prognostic value.

At the age of seven years old, it would be appropriate to see A1c tests for the next few years that are less than 8.5%, but this doesn’t mean to say that, with a successful regimen of Lantus (insulin glargine), Humalog and carbohydrate counting, you might not do better provided it isn’t offset by increasing the risk of severe hypoglycemia. In the future even lower A1c levels may be safely achieved if manufacturers are able to develop intraperitoneal glucose sensors that can last as long as a year, and if perhaps the GlucoWatch II can be made less costly and more effective.

In the teen years it becomes both more difficult and also more important to achieve good blood glucose control. The aim should be for less than7.8%. Finally, nowadays, as an adult it is often possible to maintain the A1c in the upper ranges of what is normal.

DOB