HbA1c: 6

Elle Penner, MPH, RD

5 mins

What does an A1c level of 6 mean? Are there any symptoms associated with this level?

An A1c level of 6 means that 6% of the hemoglobin in your blood is saturated with sugar. 

An A1c of 6 is considered elevated and means your blood sugar levels have been raised over the last few months. 

Elevated A1c levels of 5.7-6.4 percent are considered prediabetes. The higher your A1c, the greater your risk for developing diabetes. 

If your A1c is elevated, diet and lifestyle changes may be effective for getting your levels back into the optimal range without the need for medications. Lowering your A1c back into the optimal range (4-5.6%) can prevent or delay diabetes in the future.

An A1c of 6 doesn’t usually have any symptoms. One possible sign of prediabetes is a darkening of the skin and sometimes skin tags on certain parts of the body including the neck, armpits, elbows, knuckles, and knees.

It’s important to know the symptoms of diabetes. These include increased thirst, frequent urination, excess hunger, unintentional weight loss, fatigue, and/or blurred vision.

Factors that could contribute to an A1c level of 6: 

 A variety of factors can affect A1c levels. Some of these include:  

• Diet, particularly those high in refined carbohydrates and added sugars, and low in fiber

• Overweight/ obesity

• Being physically inactive/ sedentary 

• Age

• Race (people of Black, Hispanic/Latino, American Indian, Asian American, or Pacific Islander descent are at greater risk for prediabetes/ diabetes.)

• Stress

• Use of certain medications, including glucocorticoids

• Genetics (family history of pre-diabetes or diabetes)

• Adherence to your prediabetes/ diabetes management plan

• Pregnancy

• Chronic disease/ inflammation 

Several things can also falsely increase or decrease your A1c result. Some of these include: 

• Kidney failure, liver disease, or severe anemia

• Certain medicines, including opioids and some HIV medications

• Blood loss or blood transfusions

• Early or late pregnancy

• A less common type of hemoglobin found in people of African, Mediterranean, or Southeast Asian descent, as well as people with blood disorders like sickle cell anemia or thalassemia

Let your doctor know if any of these apply to you to determine if you need follow-up testing.

What to do if your A1c level is 6?

Adopting healthier habits and making changes to your diet can help lower your A1c levels back into the optimal range, and potentially prevent or delay a progression to diabetes. To lower your A1c:

• Be active every day: Aim for 150 minutes of moderate physical activity per week (about 30 minutes 5 days per week). 

• Fill half of your plate with non-starchy veggies at every meal, and incorporate a source of lean protein and plant-based fat to assist with blood sugar control.  

• Limit refined carbohydrates and added sugar, and choose whole-grain carbohydrates such as whole wheat bread/ pasta, quinoa, farro, and steel-cut oats, instead. 

• Lose excess weight if you are overweight or obese

• Manage stress and get adequate sleep to help balance hormone levels that can impact blood sugar

Medications used to improve A1c results

Although a medication called metformin is recommended by the American Diabetes Association and the Endocrine Society for the treatment of prediabetes, medications are typically not prescribed for an A1c level of 6.

This is likely because individuals with prediabetes are not at risk for developing the more serious microvascular complications of diabetes, like blindness and neuropathy. Also, roughly two-thirds of people with prediabetes never progress to develop diabetes. Additionally, about one-third of people with prediabetes are able to lower their A1c back into the optimal range without medication [5].

For this reason, diet and lifestyle changes are typically recommended in lieu of medications for the management of prediabetes.

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Significance of individual HbA1c targets for assessing glycemic control in patients with type 2 diabetes | Misnikova

Abstract

Currently, special attention is paid to achieving glycemic control in patients with type 2 diabetes mellitus (DM2) as a factor that determines the risk of developing macro- and microvascular complications of DM. Modern guidelines suggest an individual approach in choosing the target level of HbA _1c , taking into account age and the presence of complications.
Target.
Estimate the proportion of T2DM patients who achieved HbA targets _1c based on individual goals.
Materials and methods.
2195 patients with DM2 were examined. Patients were divided into age groups: under 45 years old, 45–64 years old, over 65 years old. In each group, two subgroups were identified: without complications and with complications (acute cerebrovascular accident, acute myocardial infarction, angina pectoris). Target HbA _1c : up to 45 years without complications ? Results.
Received hypoglycemic therapy: diet monotherapy? 301 patients (13.7%), non-insulin drugs (NIDs) ? 1335 (60.8%), combined treatment with NIR and insulin ? 319 (14.6%), insulin monotherapy? 240 (10.9%) patients. In the age group up to 45 years without complications, the target values ​​of HbA _1c were reached by 27.3% of patients, with complications ? 25% of patients; at the age of 45–64 years without complications? 30%, with complications? 35. 2%; over 65 without complications? 43%, with complications ? 55.6% of patients.
Conclusion.
With an individualized approach to assessing the achievement of treatment goals by HbA level _1c in T2DM, the proportion of people who have reached target values ​​is higher than with the traditional approach (HbA _1c

diabetes (DM), one of the main tasks of the healthcare system in many countries of the world is the development of programs aimed at improving the therapeutic and preventive care of this category of patients.In this connection, special attention is paid to achieving the goals of controlling carbohydrate metabolism in patients with type 2 diabetes (DM2) as a factor determining the risk of developing micro- and macrovascular complications.Since December 2013, a new consensus has been adopted in Russia and algorithms for specialized medical care for patients with diabetes have been developed [1], suggesting the choice of an individual treatment goal based on the level of glycated hemoglobin (HbA1c) in accordance with age patient, the presence of severe complications and the risk of hypoglycemic conditions.

Previously, the assessment of the quality of care in the region was based on the percentage of patients who achieved an average HbA1c score (7% or less). At present, this approach should be recognized as insufficient, since it does not take into account individual characteristics and, accordingly, the goals of treating patients with diabetes.

Purpose

The main purpose of the work was to determine the proportion of patients with type 2 diabetes who reached the target values ​​of HbA1c levels, based on an individual approach to treatment.

Materials and methods

The study was conducted in 12 municipalities of the Moscow region as part of a survey of patients with type 2 diabetes under the Diamobil program.

Diamobile is a mobile treatment and diagnostic module equipped with the necessary medical equipment to provide specialized endocrinological care to patients with diabetes. In the Moscow region, the diamobile leaves on a permanent basis 8 times a year, the parking time in one region is 10 working days. During this period, about 300 patients with type 2 diabetes are being examined. The formation of the list of examined patients with DM is carried out randomly by the specialists of the State Budgetary Healthcare Institution of the Moscow Region of the Moscow Regional Research Institute of Public Health on the basis of the data of the Registry of DM of the given municipality. All examined patients with DM undergo a determination of the level of HbA1c, creatinine, urea, lipidogram, an ECG is performed. After receiving the results of laboratory tests, patients are examined by specialists (ophthalmologist, surgeon, cardiologist, endocrinologist).

The article presents the results of a survey of 2195 patients with type 2 diabetes: 1770 (80.6%) women and 425 (19.4%) men. To determine individual treatment goals, patients were divided into age groups: up to 45 years, 45–64, 65 years and older. In each age group, two subgroups were distinguished: the first subgroup included patients with DM2 without complications, the second – patients with complications: acute cerebrovascular accident, acute myocardial infarction, angina pectoris.

The target HbA1c level for each subgroup was set based on the algorithms of specialized medical care for patients with diabetes mellitus [1] (Table 1).

Determination of glycated hemoglobin was carried out on the device NicoCard Reader II (Axis-Shield), Norway, by the method of borate affinity analysis. The test is NGSP certified as a DCCT reference method.

General characteristics of patients. The average duration of DM2 in the examined patients was 9.4±7.7 years. The duration of the disease was up to 5 years in 699 patients (31.8%), 5-9 years – 599 people (27.3%), 10-14 years – 438 (20%), 15-19 years – 197 (9%) and more than 20 years – 262 patients (11.9%).

The mean body mass index (BMI) was 33.21±6.1 kg/m2. The normal value of BMI was registered in 6.7% of the examined, overweight – in 24.7%, obesity of the 1st degree occurred in 33.7%, obesity of the 2nd degree – in 22.8%, obesity of the 3rd degree – at 12.6%. Thus, obesity or overweight was reported in 93. 3% of patients, with 12.6% having morbid obesity.

By age groups, patients were distributed as follows: group under 45 years old – 59people (2.7%): without complications – 55 people (2.5%) and with complications – 4 people (0.2%). Age group 45-64 years – 1291 patients (58.8%): without complications – 944 people (43.0%), with complications – 347 people (15.8%). At the age of 65 years and older – 845 people (38.5%): 419 (19.1%) – without complications and 426 (19.4%) – with complications.

As concomitant therapy, only antihypertensive drugs were received by 847 patients (38.6%), only lipid-lowering drugs – 83 (3.8%), a combination of antihypertensive and lipid-lowering drugs – 1155 people (52.6%), and 110 patients ( 5%) did not receive the indicated concomitant therapy.

Statistical processing of the material was carried out using the standard Excel package. Data are presented as mean ± standard deviation

Results

The mean HbA1c in the study sample was 8. 2±2.9%. Of the total number of patients with DM2, 28.8% achieved the level of HbA1c<7%, more than 9% had 29.7%. The distribution of patients depending on the level of HbA1c is shown in fig. 1.

In general, 38.2% of patients with type 2 diabetes achieved individual target values ​​for HbA1c levels. The highest percentage of patients who achieved individual treatment goals was registered in the group of 65 years and older: among those without complications it was 43%, with complications – 55.6% (Fig. 2). The worst indicators were found in the age group up to 45 years: both without complications, where the target values ​​of HbA1c were reached by 27.3% of patients, and with complications – 25%. This is largely due to the fact that this age group has the most stringent target values. In the age group 45-64 years without complications, 30% of patients reached the target values, with complications – 35.2%. The percentage of patients who reached the target values ​​was slightly higher in the group with complications, both at the age of 45–64 years (30 and 35. 2%) and 65 years and older (43 and 55.6%). At the same time, at the age of up to 45 years, this percentage practically does not differ between groups.

Mean HbA1c levels were not significantly different between those aged 45–64 years and those aged 65 years and older, and were similar between those with and without complications (Table 2). In patients under 45 years of age, the average HbA1c value was lower in the group of patients who did not have complications compared to people of the same age with complications. It should be noted that due to the small number of younger age groups with complications, the results may be of limited value.

Depending on the type of hypoglycemic therapy received, the patients were distributed as follows: the majority were treated with non-insulin antidiabetic drugs (NIR) – 1335 (60.8%). The total number of patients receiving insulin therapy was 559people (25.5%), including those on combined treatment with oral hypoglycemic drugs (OSSP) and insulin 319 (14. 6%), on insulin monotherapy – 240 (10.9%). A fairly large number of patients remained on monotherapy with a diet and did not receive drug hypoglycemic therapy – 301 people (13.7%) (Fig. 3).

Of the NIR (no insulin) group, 48.3% were treated with a single drug and 51.7% were treated with 2 or more NIRs.

According to the structure of hypoglycemic therapy in the examined sample of patients, comparable results were obtained in comparison with the data of the Register of Patients with Diabetes in the Moscow Region. Thus, the number of patients receiving insulin monotherapy practically coincides (according to the Register – 9%), and those who were on monotherapy with a diet (according to the Register – 11.7%).

At the same time, there was a slightly larger number of patients in the study sample, compared with the data of the Register, receiving insulin in combination with NID (14.6% and 8.7%), and fewer patients who were on NID monotherapy (60.8% and 70.6%).

Metformin was used as a first-line hypoglycemic drug in 39. 4% of patients, a significant number of patients (59.2%) received monotherapy with sulfonylurea drugs (glibenclamide – 34.9%, gliclazide MB – 15.2%, glimepiride – 5.7%, gliquidone – 3.4%), less than 1.5% of patients were prescribed drugs of other groups (pioglitazone – 0.9%, drugs of the incretin group – 0 ,5%). In the combined treatment with insulin and PSSP, metformin was most often prescribed – in 37.4%, somewhat less frequently (in 31.5%) – drugs from the sulfonylurea group (glibenclamide – 21.9%, gliclazide MB – 4.8%, glimepiride – 3 .2%, gliquidone – 1.6%). Pioglitazone in combination with insulin was prescribed in 0.3%. 30.8% of patients in combination with insulin received two or more PSSPs.

Thus, in general, metformin was most often prescribed as a basic hypoglycemic drug, it was taken by 1162 people (52.9% of the total number of patients).

In each treatment group, the majority of patients did not achieve individual target values, including those who did not receive hypoglycemic medication (Table 3), which indicates the need for more active tactics in the treatment of diabetic patients and early prescription of antidiabetic drugs. The average HbA1c level on insulin therapy was above 8% in all age groups, which indicates the need for more active titration of insulin doses, and, if necessary, transfer to an intensified insulin therapy regimen with the addition of short-acting insulin.

Discussion

Analysis of the results of the study showed that a fairly large proportion of patients with DM2 – 71.2% do not reach HbA1c values ​​<7%, which is comparable to the data for the Russian Federation as a whole, where it was 74.8% [2]. At the same time, 48.1% of patients in the sample had an HbA1c level >8%, while according to some other studies, 57.4% of patients living in the Russian Federation had a similar HbA1c level [3]. In some foreign countries, the situation is somewhat better, but, nevertheless, a similar trend continues. In particular, according to the National Institute of Health and Clinical Research (NHANES), only 50% of patients with type 2 diabetes in the United States had HbA1c≤7.0%, about 20% – in the range from 7% to 8%, and about 30% had at the time of the survey pronounced decompensation of carbohydrate metabolism: HbA1c≥8. 0% [4]. The obtained results indicate insufficient control of carbohydrate metabolism in patients with type 2 diabetes, and if the achievement of the level of HbA1c <7%, and even more so <6.5% is currently not relevant for all patients with type 2 diabetes, then the percentage of patients with HbA1c>8%, and especially >9% can characterize the quality of diabetic care in the region.

UKPDS (UK Prospective Diabetes Study), ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation), VADT (Veterans Affairs Diabetes Trial) have shown that intensive blood glucose control is associated with a reduced risk of microvascular disease. complications that cause disability and mortality in a large number of patients with type 2 diabetes [5–8]. The role of intensive glycemic control in the prevention of macrovascular complications of DM is less clear [9]. It is possible that the reduction in the risk of macrovascular complications with intensive glycemic control does not occur due to the worsening of the course of cardiovascular disease due to hypoglycemia in a certain group of individuals. On the contrary, too intense glycemic control may be associated with increased cardiovascular mortality, as happened in the ACCORD study (The Action to Control Cardiovascular Risk in Diabetes) [10]. On the other hand, it is obvious that the potential risk of developing hypoglycemic reactions in some patients should not stop the physician from setting strict treatment goals for T2DM patients with a good life prognosis, without severe comorbidities.

In general, according to our study, individual target values ​​for HbA1c levels were reached by a larger number of patients with type 2 diabetes compared with the average HbA1c <7% - 38.2% and 28.8%, respectively. The smallest number of patients who reached the target levels of HbA1c was registered at a young age (under 45), which is probably due to the most stringent compensation criteria provided for patients in this age group. At the same time, strict compensation criteria are absolutely justified, since the achievement of optimal control of carbohydrate metabolism among people of this age group will contribute to the prevention of complications of diabetes and the prevention of related disability and increased mortality among people of working age.

According to the results of the study, it was found that in the group of young patients on monotherapy with a diet, only 16.7% of persons reached the target values ​​of the HbA1c level. Accordingly, a more active prescription of hypoglycemic therapy is necessary already at the time of establishing the diagnosis of DM2, especially in young people in the absence of severe comorbidity. At the same time, in the age group of 65 years and older, the number of patients with satisfactory glycemic control on the diet was quite high – 75.8% in persons without complications and 83.9%% with complications. This is due to lower, more easily achievable, glycemic targets and possibly better dietary compliance in older patients. Thus, the use of a diet as a monotherapy is advisable only in older people, while in middle-aged and young patients it is necessary to determine the level of HbA1c every 3 months and add the base drug in a timely manner in order to achieve target glycemic values ​​without waiting for the occurrence and progression of complications. SD. In this regard, it should be noted the need for a more active prescription of metformin, the basic drug for the treatment of type 2 diabetes. Until recently, widespread use of metformin has been somewhat limited due to the risk of gastrointestinal side effects. The need for 2 or 3 doses of the drug reduced the compliance of patients. Currently, an extended form of metformin, Glucophage Long, is registered and widely prescribed in Russia. The risk of side effects from the gastrointestinal tract is much lower with its use compared with the use of the traditional form of metformin, and adherence to treatment is higher due to the possibility of taking it once a day.

Considering that in patients who are already prescribed hypoglycemic therapy, in each treatment group there is also a rather low percentage of people who have achieved their individual treatment goals, it is necessary to prescribe NIR at an effective dose, and in the absence of achievement of target HbA1c values, more actively use combined drugs or combinations of NIR.

According to a study conducted in 7 European countries, only 25.5% of patients with type 2 diabetes receiving combination therapy with metformin with glitazones or with sulfonylurea drugs had satisfactory indicators of the state of carbohydrate metabolism [11]. This indicates the need for timely addition of insulin therapy to the treatment.

In our study, among patients receiving combined treatment with insulin and PSSP, there was a low percentage of individuals who reached the target HbA1c values. Mean HbA1c levels on insulin therapy were above 8% in all age groups. Such a low level of achievement of HbA1c target values ​​indicates a late prescription of insulin therapy for patients on NIIR, inadequate titration of insulin doses, the need to train patients in self-monitoring of glycemia and timely decision-making on insulin dose adjustment and insulin therapy regimen.

Conclusions

1. With an individual approach to assessing HbA1c target values ​​in T2DM, the proportion of people who achieved them is higher than with the traditional approach (HbA1c<7. 0%): 38.2 and 28.8%, respectively.
2. In all groups of patients with DM2, there is a fairly high percentage of people who have not achieved treatment goals, which indicates the need for timely intensification of hypoglycemic therapy.
3. In young and middle-aged patients who are on monotherapy with a diet, there is a relatively low proportion of people who have achieved treatment goals, and therefore it is advisable to prescribe drug hypoglycemic therapy earlier in this age group of patients.
4. In the group of patients receiving combined treatment with PSSP and insulin, there is the lowest proportion of individuals who have achieved individual treatment goals, which requires timely titration of the insulin dose and correction of the insulin therapy regimen with the possible addition of short-acting insulin.

Information about the conflict of interest

The authors declare no conflict (duality) of interest when writing this article.

Glycosylated hemoglobin test in Kyiv

Glycosylated hemoglobin HbA1c

Glycosylated hemoglobin HbA1c is a test used to detect the chemical combination of hemoglobin (found in red blood cells) with glucose. The analysis shows the average value of glucose in the blood over the past three months.

Blood glucose binds to hemoglobin to form a stable compound, glycosylated hemoglobin. Hemoglobin A, one of several normal types of this protein, ranges from 95% to 98% of all hemoglobin in the body. The more glucose in the blood, the higher the glycated hemoglobin HbA1c.

You can find different names for this indicator:

• A1c
• Glycated hemoglobin
• Glycosylated hemoglobin
• Hemoglobin A1C

Indications for testing glycosylated hemoglobin

An appointment for testing glycosylated hemoglobin HbA1c can be prescribed by a physician or endocrinologist. The analysis is prescribed for people with suspected diabetes, namely those who have one of the following indicators:

• intense thirst,
• frequent profuse urination,
• fatigue,
• blurred vision,
• increased susceptibility to infections.

In addition, this analysis evaluates the effectiveness of treatment and its adjustment (if necessary) and for the prevention of diabetes.

Patients with diabetes mellitus undergo this analysis 2 times a year, and in case of severe leakage, 4 times a year.

Analysis for glycated hemoglobin – reference Values ​​(laboratory standards)

For analysis of glycated hemoglobin, capillary or venous blood is taken.

The American Diabetes Association recommends that HbA1C levels be 7% or lower, and the closer this is to 6% without risk to health, the better.

This laboratory test is widely used to assess the degree of compensation of diabetes mellitus:

• A glycated hemoglobin level of 4.8-6.0% indicates good diabetes compensation in the last 1-1.5 months,
• 6.0-8.9% – about subcompensation of the disease,
• more than 9.0% – about decompensation and the need to adjust antidiabetic therapy.