What are the updated American Diabetes Association (ADA) guidelines for Hemoglobin A1c (HbA1c) targets in children, adolescents, and older adults with type 2 diabetes?

Updated ADA HbA1c Targets for Children, Adolescents, and Older Adults with Type 2 Diabetes

For children and adolescents with type 2 diabetes, target an HbA1c <7% (53 mmol/mol) as the standard goal, with more aggressive targets of <6.5% (48 mmol/mol) reserved for select patients on lifestyle or metformin monotherapy who can achieve this safely without hypoglycemia. 1

Children and Adolescents with Type 2 Diabetes

Standard Target: <7% (53 mmol/mol)

• The baseline HbA1c goal for most youth with type 2 diabetes is <7% (53 mmol/mol), which is appropriate for those treated with oral agents alone or insulin. 1
• This target is justified by the lower risk of hypoglycemia in youth-onset type 2 diabetes compared to type 1 diabetes, while acknowledging the higher risk of long-term complications in this population. 1

More Stringent Target: <6.5% (48 mmol/mol)

Consider an HbA1c target of <6.5% (48 mmol/mol) specifically for youth who meet ALL of the following criteria: 1

• Short duration of diabetes at diagnosis
• Lesser degrees of β-cell dysfunction
• Treated with lifestyle modifications or metformin monotherapy only (with or without long-acting insulin)
• Achieving significant weight improvement
• Can reach this target without significant hypoglycemia or adverse treatment effects

Less Stringent Target: <7.5% (58 mmol/mol)

Relax the target to <7.5% (58 mmol/mol) when there is increased risk of hypoglycemia. 1

Key Implementation Points

• Assess glycemic status every 3 months with HbA1c measurement. 1
• Individualize blood glucose monitoring based on the patient's pharmacologic treatment regimen. 1
• Consider real-time or intermittently scanned continuous glucose monitoring for youth on multiple daily insulin injections or insulin pumps who can use the device safely. 1

Older Adults with Type 2 Diabetes

Risk-Stratified Approach Based on Life Expectancy and Comorbidities

The VA/DoD guidelines provide the most comprehensive framework for older adults, stratifying targets by life expectancy and comorbidity burden: 1

Healthy Older Adults (Life Expectancy >10-15 years)

• Target HbA1c: 6.0-7.0% if achievable safely 1
• This applies to those with absent or mild microvascular complications
• Individual preferences must be incorporated into target selection

Older Adults with Moderate Comorbidity (Life Expectancy 5-10 years)

• Target HbA1c: 7.0-8.5% 1
• This range is appropriate for those with established microvascular or macrovascular disease
• Also applies to those with significant comorbid conditions

Frail Older Adults (Life Expectancy <5 years)

• Target HbA1c: 8.0-9.0% 1
• Use this range for patients with advanced diabetes complications, significant comorbidities, or difficulties with self-management
• Consider factors like mental status, disability, food insecurity, and insufficient social support

Critical Considerations for Older Adults

• The emphasis is on target ranges rather than fixed values, with safety being paramount—targets should only be pursued if achievable without significant hypoglycemia. 1
• The American College of Physicians recommends a target range of 7-8% for most nonpregnant adults with type 2 diabetes, considering individual patient characteristics and hypoglycemia risk. 2
• Assess non-glycemic factors that affect HbA1c interpretation, including race, ethnicity, chronic kidney disease, and laboratory methodology. 1

Diagnostic Criteria (Universal for All Ages)

• HbA1c ≥6.5% (48 mmol/mol) confirms diabetes diagnosis 2
• HbA1c 5.7-6.4% (39-46 mmol/mol) indicates prediabetes 2

Important Caveat for Pediatric Diagnosis

The ADA acknowledges limited data supporting HbA1c for diagnosing type 2 diabetes in children and adolescents, and it should NOT be used for diagnosis in children with cystic fibrosis or symptoms of acute-onset type 1 diabetes. 1 Research demonstrates that HbA1c has poor sensitivity (68%) and specificity (78%) for detecting type 2 diabetes in obese youth, with an optimal threshold of 5.8% rather than 6.5%. 3

Common Pitfalls to Avoid

• Do not pursue HbA1c <6.5% in older adults with multiple comorbidities or high hypoglycemia risk—this significantly increases morbidity without proven mortality benefit. 2
• Avoid using HbA1c alone for diagnosis in obese children—it underestimates diabetes prevalence and misses many cases only detectable by oral glucose tolerance testing. 3, 4
• Do not apply fixed targets without considering individual patient factors—race, ethnicity, hemoglobinopathies, and chronic kidney disease all affect HbA1c interpretation. 1
• Failing to reassess targets as circumstances change—targets must be adjusted as patients age, develop complications, or experience changes in life expectancy. 1, 2