Are the current American Diabetes Association (ADA) guidelines for Hemoglobin A1c (HbA1c) targets in patients with type 2 diabetes, including children, adolescents, and older adults, up to date?

Current ADA HbA1c Guidelines Are Up to Date

The most recent 2023 ADA guidelines for HbA1c targets in type 2 diabetes remain current and evidence-based, with specific recommendations stratified by age group and health status. 1

Adult HbA1c Targets (Non-Elderly)

For most non-pregnant adults with type 2 diabetes, the ADA recommends:

• Target HbA1c <7% (53 mmol/mol) for the majority of patients 1
• More stringent targets of <6.5% (48 mmol/mol) may be appropriate for selected individuals if achievable without significant hypoglycemia, particularly those with short disease duration, long life expectancy, or no significant cardiovascular disease 1
• Less stringent targets of <8% (64 mmol/mol) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced complications, or extensive comorbidities 1

Children and Adolescents with Type 2 Diabetes

The 2023 ADA guidelines provide clear targets for pediatric populations:

• Target HbA1c <7% (53 mmol/mol) for most children and adolescents with type 2 diabetes 1
• More stringent targets of <6.5% (48 mmol/mol) are appropriate for selected individuals with short disease duration, lesser degrees of β-cell dysfunction, or those treated with lifestyle/metformin only who achieve significant weight improvement 1
• Less stringent targets of 7.5% (58 mmol/mol) may be appropriate if there is increased risk of hypoglycemia 1
• Glycemic status should be assessed every 3 months in all pediatric patients 1

Older Adults (≥65 Years)

The guidelines for older adults are stratified by health status, which represents a critical update:

Healthy Older Adults

• Target HbA1c 7.0-7.5% (53-58 mmol/mol) for relatively healthy older adults with few coexisting chronic illnesses, intact cognitive and functional status, and longer life expectancy (>10 years) 2

Complex/Intermediate Health Status

• Target HbA1c <8.0% (64 mmol/mol) for patients with multiple coexisting chronic illnesses, 2+ instrumental activities of daily living impairments, or mild-to-moderate cognitive impairment 2

Very Complex/Poor Health Status

• Target HbA1c 8.0-8.5% (64-69 mmol/mol) or higher for frail older adults, those in long-term care, patients with end-stage chronic illnesses, moderate-to-severe cognitive impairment, or 2+ activities of daily living dependencies 2
• This includes patients with life expectancy <5 years, history of severe hypoglycemia, or advanced complications 2

Key Diagnostic Criteria (Unchanged Since 2018)

The diagnostic criteria remain stable:

• HbA1c ≥6.5% (48 mmol/mol) confirms diabetes diagnosis when performed in a laboratory using NGSP-certified methods 1
• Confirmation testing is required unless there is clear clinical diagnosis with hyperglycemic crisis 1
• Two different tests above diagnostic threshold (such as HbA1c and fasting plasma glucose) also confirm diagnosis 1

Important Caveats and Pitfalls

Age-Related Considerations

• HbA1c diagnostic criteria were validated only in adult populations, so uncertainty remains about using the same cutpoint for diagnosing diabetes in children and adolescents 1
• Despite this limitation, the ADA continues to recommend HbA1c for diagnosis of type 2 diabetes in children to reduce screening barriers 1

Conditions Where HbA1c Is Unreliable

• Do not use HbA1c for diagnosis in children with cystic fibrosis or symptoms suggestive of acute onset type 1 diabetes 1
• Hemoglobin variants can interfere with HbA1c measurement, though most US assays are unaffected by common variants 1
• Conditions with increased red blood cell turnover (sickle cell disease, pregnancy second/third trimesters, hemodialysis, recent blood loss/transfusion, erythropoietin therapy) require plasma glucose criteria only 1

Monitoring Frequency

• HbA1c should be measured every 3 months until glycemic targets are achieved 1
• Once stable and at target, measure at least twice yearly 1
• For older adults meeting individualized targets for several years, every 12 months may be sufficient 2

Evidence Supporting Current Guidelines

Recent research validates the ADA's health status-based approach in older adults. A 2021 ARIC study demonstrated that older adults with very complex/poor health and HbA1c ≥8% had significantly higher mortality (HR 1.76) and hospitalization rates (IRR 1.41) compared to those with HbA1c <7%, supporting individualized targets rather than universal relaxation 3. Importantly, older adults with HbA1c <7% were not at elevated risk regardless of health status, indicating that <7% remains a reasonable goal when safely achievable 3.

The guidelines appropriately balance microvascular risk reduction against hypoglycemia risk, recognizing that years of intensive control are required before microvascular benefits manifest—making aggressive targets inappropriate for those with limited life expectancy 2.