If you didn't believe my friend and former UTHSCSA colleague John Steinberg before, please research it yourself because it is true. And hey, why aren't you believing John in the first place?? There is something wrong with that decision!

I have been researching this myself and for personal reasons. My dear husband of three decades-plus went to our family physician recently and came home with his lab results in hand. I was suspicious for a few reasons. Some skin tags and other things that I won't go into here for personal reasons. I expected to see an elevated blood glucose level and an elevated HgA1C. 

His blood glucose level, a fasting blood glucose was 130. Too high. I scanned the results for his HgA1C and.....I didn't find it there. I was shocked! She had failed to order a HgA1C. As a podiatric physician, I often ordered a HgA1C for my patients who were having difficulty healing their wounds.

I asked my husband what our physician had told him. Her recommendation was.......Try to cut back on concentrated sweets and carbs. Nothing else.

I always had admired our internist and thought that she was on the cutting edge  but this made me take a second look at her.  Obviously, my husband has diabetes. Not "pre-diabetes. Not syndrome X, not any quasi-diabetes but a real diabetic condition if his fasting blood sugar is 130. The "normal" for blood sugar dropped to 70-110 years ago. When was the last time she checked in on that value??

Not really what he wanted to hear and if his "real doctor" didn't say it, he didn't want to hear it. But I've been preparing meals more carefully. Next time we visit our MD together, you bet I'll be asking her to order a HgA1C and taking her the literature to back up my request.

So if our MD/DO colleagues aren't respecting the HgA1C as the real test of diabetes, I believe that they are actually committing a form of malpractice in a sense.

It's funny that UCLA put out an article in JAMA in 1997 looking at HGA1c as a prognostic tool to asses DM, but it wasn't until this past year the ADA finally embraced this study as an alternative study to help with diagnosis. 
"The committee has established an HbA1c cut point of ≥6.5% for the diagnosis of diabetes. Further, a level ≥6% but <6.5% is sufficient to identify individuals at especially high risk for diabetes, the committee said."

but when u read further u see there are pitfalls such as Hga1c naturally goes up in African Americans (having a higher Hga1c when compared to whites sex, age and gender controlled) and with age. 

I totally agree, Khan. Can you believe that it has taken the rest of the world so long to agree with what we discovered to be true in the mid-90's or earlier at UT. I am often amazed at what we were doing there. It is not a put down to anyone. No way. It s only a testament of sorts to the extreme poverty, the number of patients and the extent of the disease experienced by the patients. Not exactly something to crow about is it. But by those extremes that we were exposed to, we did get to experience treatments on a fast track. In some ways it was a blessing. One I think that you will agree that we did not always appreciate.

There is no secret to this alchemy, is there?

I agree with all the above posts above. I am always amazed at how infrequently some internists/family physicians are utilizing a glycosylated hemoglobin A1c and the extent of diabetes mellitus that is being under-reported and under-diagnosed. This is extremely complicated when patients have blood tests performed in a fasted state for 12-16 hours for LDL/HDL monitoring. It is for this reason alone that glycosylated hemoglobin A1cs should be run since we all know that if you take a recent-onset diabetic patient and fast that person for 12 hours, the hyperglycemic state of that patient may appear normal to near-normal range.

I often see patients referred to me who do not meet the diagnostic criteria for diabetes of either two fasting blood sugars above 125 or two random blood sugars above 200, however the hemoglobin A1c is above 6.4. I think that the hemoglobin A1c picks up many patients who have been falling through the cracks.   Unfortunately, until insurance companies (including Medicare) accept this as a diagnosistic criteria, nutrition therapy, which is always a cornerstone of diabetes treatment, for these patients is not yet covered.

Carol Sherman, MPH, RD, LD/N, CDE