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An A1c Of Greater Than 5.4% Can Signal Undiagnosed Diabetes

Oct 22, 2008

At-risk individuals with an HbA1c test level of 5.4% or greater can signal undiagnosed diabetes and certainly prediabetes, according to new study findings.

At-risk individuals with an HbA1c test level ≥6.1% are more likely to have undiagnosed diabetes, according to new study findings.

Adit Ginde, MD, MPH, assistant professor of surgery, division of emergency medicine at the University of Colorado Denver School of Medicine, stated that,  “There are many advantages in efficacy of HbA1c vs. fasting glucose or glucose tolerance testing. Our results provide additional support that HbA1c can be an effective method to identify undiagnosed diabetes in at-risk patients,”

Ginde and colleagues evaluated the predictive validity of HbA1c as a screening test in 6,723 NHANES 1999-2004 participants. The estimated prevalence of undiagnosed diabetes (fasting plasma glucose ≥126 mg/dL) in the United States population was 2.8%, or 5.5 million people.

The researchers derived a risk score for undiagnosed diabetes and stratified participants into prevalence risk subgroups: low (0.44%), moderate (4.1%) and high (11.1%).

“HbA1c is very effective in screening for undiagnosed diabetes when patients are stratified into risk groups,” Ginde said. Risk factors and independent predictors of undiagnosed diabetes were older age, male sex, black race, hypertension, elevated waist circumference, elevated triglycerides and low HDL.

More than half of high-risk individuals with HbA1c ≥6.1% had undiagnosed diabetes. Among those with a combination of risk factors, HbA1c levels as low as 5.4% can signal undiagnosed diabetes, according to Ginde. Diabetes can be reliably excluded with HbA1c <6.1% in moderate-risk patients and <5.5% in high-risk patients, he said.

In August, a consensus panel recommended HbA1c testing be used as a frontline method for identifying patients at risk for diabetes. Additionally, the panel recommended that HbA1c ≥6.5% be accepted as a criterion for diagnosing diabetes. These findings suggested an even lower cut-off point.

With any patient, “evaluate diabetes risk factor profile and consider HbA1c as an initial test to screen for undiagnosed diabetes in moderate- and high-risk patients in nonfasting visits,” Ginde said.

Dr. Ginde’s comments reinforces an increasing trend among endocrinologists and other medical specialists to favor the A1c test for detecting type 2 diabetes, rather than current "moment-in-time" tests that rely heavily on patients’ adherence to fasting requirements.

HbA1c Level Signaling Undiagnosed
Diabetes in At-Risk Patients

≥ 6.1%

Requires confirmatory fasting plasma glucose

5.5% to 6%

May exclude diabetes in moderate-risk but not high-risk groups


May reliably exclude diabetes

J Clin Endocrinol Metab. 2008;93:2447-2453.  / J Gen Intern Med. 2008;23:1346-1353.


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