Why Is Everyone Worried about A1c Overtesting?

Disclosure for me – I am a person with type 2 diabetes and am managing my diabetes with insulin. I only have two HbA1c tests per year and I do not feel this is often enough. Admittedly, I discontinued seeing an endocrinologist because I was consistently being asked to raise my A1c to level above 7.5%. When my A1c was under 6.5%, I was told rather sternly to let my A1c rise. I, of course do not believe this and believe I should manage my glucose levels to the best of my ability.

Fortunately, my VA nurse practitioner believes this also and with the other tests they run, she can determine that my meal plan is not affecting my health and the tests clearly show this. So I will continue to follow the low carb, high fat, moderate protein food plan and hopefully my next A1c test will be better and I won't have a couple of infections and another problem that will keep it as high.

It seems that certain doctors feel that for persons with well-managed diabetes, that they only need at most two HbA1c tests per year. Fortunately, some doctors disagree and feel that their patients need four tests per year. And some individuals buy their own kits to test on a monthly basis. This must drive these doctors into a tizzy.

Dr. Rozalina McCoy, a professor of medicine at the Mayo Clinic, in Rochester, Minn. is one of these doctors and a lead researcher that states - "I think part of the problem is that we often think more testing is better."

Her research showed that over 60% of adults in the United States with well-controlled type 2 diabetes receive more than the recommended number of tests for HbA1c. And excessive testing increases the risk of treatment being intensified despite a patient having normal HbA1c levels, a new retrospective analysis of an administrative claims database demonstrates.

The test, which gauges a person's average blood sugar control over the past three months, is routinely used to diagnose and monitor type 2 diabetes. But guidelines say it should be done only once or twice a year if a patient has been showing good blood sugar control, according to the study.

First, the HbA1c test reflects the prior four months and this is from David Mendosa's blog. I think this is a common mistake that the article author made, as the author of the second article did not even mention this.

"I think the most important drivers of HbA1c overtesting in the US are multifactorial," Dr McCoy told Medscape Medical News.

She and her colleague identified some factors that seem to play a role in how frequently patients are tested, including the number of different healthcare providers each patient sees and whether their endocrinologist also treats type 1 diabetes patients, who do require more frequent monitoring. Also, there was a wide geographic variation in frequency of testing.

Current guidelines recommend patients with stable glycemic control receive HbA1c tests once or twice a year. While this is true, often once a year is insufficient and because the American Diabetes Association only recommends A1c tests, patients often need to pay for their own test strips or completely operate in the dark. Dr. Robert Ratner, chief scientific and medical officer for the ADA that says, “Many people with type 2 diabetes who are on medications don't need to do home glucose monitoring at all," in talking about oral medications.

With all this stacked against diabetes patients, it is small wonder, many patients see several doctors to be HbA1c tested several times per year. Unlike the following statement, with the ADA against you, I believe that overtesting of HbA1c is over researched. This is just another way the medical community is working to harm patients with well managed type 2 diabetes.  The researchers also use a value of A1c greater that 7 percent for increased A1c testing.  When will they learn that A1c values above 6.5 percent can lead to complications.  It is no small wonder that this is why doctors consider type 2 diabetes progressive.  They want to limit testing and give no education.

“And in an accompanying editorial, Rodney Hayward, MD, University of Michigan, Ann Arbor, says the current study "probably greatly underestimates" the size of the overtreatment problem among US patients with type 2 diabetes. This common belief that there is "no harm in looking" continues to result in not just waste in the healthcare system but palpable patient harm, he stresses.”

For an HbA1c test the cost is very reasonable and a few extra tests are minimal cost and often great security for type 2 patients and generally create little harm.

Do You Know the HbA1c Test?

Many of my peers have written on this topic, but now is my attempt. I do receive emails asking me “what is the best HbA1c?” I answer that if you do not have diabetes, normal HbA1c should be between 4.2% and 5.6%, meaning the person is healthy and at minimum risk of diabetes. I have seen others say it should be between 4.2% and 4.8% for normal healthy individuals, and generally, these indicate no risk for diabetes. In all of this, I advise you to read this by David Mendosa. He did his research and speaks to the subject of normal being 4.7% to 5.7%.


These same people say that there is minimal risk for diabetes between 4.9% and 5.6%; however, they advise paying closer attention if this starts to creep up toward 5.7%. The range from 5.7% to 6.4% is ignored by most doctors and treated in a cavalier way. In reality, this range is for diagnosis of pre-diabetes, but don't rely on most doctors doing anything about it. If you have a history of diabetes in your family, are overweight, or having any of the symptoms of diabetes, make sure that your doctor is aware of this. Your risk for diabetes is higher than it should be.


Once your HbA1c crosses into the 6.5% or higher level, you have diabetes. Forget about arguing that you don't have diabetes. Your pancreas is having trouble producing enough insulin or your insulin resistance is preventing the insulin your pancreas is producing from being utilized. Now that I have said this, many doctors can't get away from the teachings of the American Diabetes Association (ADA), which declares diabetes starts at 7.0%. Even this is outdated, but in the recent past this was the crossing point for diabetes and many doctors cling to this.


I will advise people who have diabetes in their family history and their doctor will not test for diabetes to find an endocrinologist that will test them for diabetes and to do this a minimum of once per year. No I did not say fire your current doctor as with the changes happening under the Affordable Care Act (ACA), this may not be a good time to be without a doctor.


Patients with anemia, those taking vitamin C and E, patients with high blood cholesterol levels, and people with liver or kidney diseases need to be aware that they may have abnormal HbA1c tests. Be prepared to discuss this with your doctor and especially if you are taking supplements. Be careful and manage your diabetes as those who do not manage their diabetes have a much higher risk of developing the complications.


How often you should have the HbA1c test is another area for concern. I don't say this lightly as doctors vary considerably in how often they wish to test you. Some of this depends on how well you are managing your diabetes. If you are self-motivated and are always below 6.0% most doctors may wish to only test your HbA1c every six months. Some doctors will still insist on testing your quarterly. You should always strive to have HbA1c tests below 6.5% although some will say less than 7% - again this is the recommendation of the ADA.


I do appreciate what David Mendosa recommends in his blog. I will admit that being able to have the test strips for checking my blood glucose as frequently as I need has kept me from following his advice. Read the complete blog as he points out the importance of monthly HbA1c testing.