Intended for healthcare professionals

Practice 10-Minute Consultation

A borderline HbA1c result

BMJ 2019; 365 doi: (Published 11 April 2019) Cite this as: BMJ 2019;365:l1361
  1. Eleanor Barry, NIHR Doctoral Research Fellow and GP1,
  2. Samuel Finnikin, Academic GP2
  1. 1Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  2. 2University of Birmingham, Birmingham, UK
  1. Correspondence to S Finnikin S.J.Finnikin{at}
  • Accepted 22 March 2019

What you need to know

  • Using HbA1c thresholds for pre-diabetes alone will not identify those at greatest risk of developing diabetes

  • Consider other risk factors when assessing an individual’s risk of developing diabetes

  • People at high risk of developing diabetes who are able to engage with intensive lifestyle interventions can reduce this risk

  • Discuss the harms and benefits of screening for diabetes with patients, particularly if they are unlikely to progress to clinically meaningful diabetes

A 55 year old white man attends his annual hypertension review. His glycated haemoglobin (HbA1c) is 44 mmol/mol. He has a body mass index (BMI) of 31 kg/m2 and his cholesterol is raised.

Pre-diabetes is an umbrella term used to describe blood glucose levels that are above normal but below the diagnostic threshold for diabetes.1 In practice this is most commonly where a patient’s glycated haemoglobin (HbA1c) value is between 42 and 48 mmol/mol, but it also encompasses impaired fasting glucose and impaired glucose tolerance. The term “pre-diabetes” is the subject of much debate, with some favouring “non-diabetic hyperglycaemia.” This reveals an underlying tension between a desire to prevent a medical diagnosis (diabetes) and the potential harms of over-medicalising people based on laboratory proxies for health.2 In this article we outline our approach to a consultation with someone with a borderline HbA1c approach.

What you should cover

The initial focus of the consultation is to establish the patient’s individual risk of developing diabetes. This will enable an informed discussion of that risk and the options available.

A blood test in isolation will not identify those at greatest risk of developing diabetes. Those with the greatest progression rates are people with dysglycaemia and multiple risk factors for diabetes. These are listed in box 1. To identify those most at risk …

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