Racial Differences in the Relationship of Glucose Concentrations and Hemoglobin A1c Levels

Ann Intern Med. 2017 Jul 18;167(2):95-102. doi: 10.7326/M16-2596. Epub 2017 Jun 13.


Background: Debate exists as to whether the higher hemoglobin A1c (HbA1c) levels observed in black persons than in white persons are due to worse glycemic control or racial differences in the glycation of hemoglobin.

Objective: To determine whether a racial difference exists in the relationship of mean glucose and HbA1c.

Design: Prospective, 12-week observational study.

Setting: 10 diabetes centers in the United States.

Participants: 104 black persons and 104 white persons aged 8 years or older who had had type 1 diabetes for at least 2 years and had an HbA1c level of 6.0% to 12.0%.

Measurements: Mean glucose concentration, measured by using continuous glucose monitoring and compared by race with HbA1c, glycated albumin, and fructosamine values.

Results: The mean HbA1c level was 9.1% in black persons and 8.3% in white persons. For a given HbA1c level, the mean glucose concentration was significantly lower in black persons than in white persons (P = 0.013), which was reflected in mean HbA1c values in black persons being 0.4 percentage points (95% CI, 0.2 to 0.6 percentage points) higher than those in white persons for a given mean glucose concentration. In contrast, no significant racial differences were found in the relationship of glycated albumin and fructosamine levels with the mean glucose concentration (P > 0.20 for both comparisons).

Limitation: There were too few participants with HbA1c levels less than 6.5% to generalize the results to such individuals.

Conclusion: On average, HbA1c levels overestimate the mean glucose concentration in black persons compared with white persons, possibly owing to racial differences in the glycation of hemoglobin. However, because race only partially explains the observed HbA1c differences between black persons and white persons, future research should focus on identifying and modifying barriers impeding improved glycemic control in black persons with diabetes.

Primary funding source: Helmsley Charitable Trust.

Publication types

  • Multicenter Study
  • Observational Study

MeSH terms

  • Adolescent
  • Adult
  • Black People*
  • Blood Glucose / metabolism*
  • Blood Glucose Self-Monitoring
  • Child
  • Diabetes Mellitus, Type 1 / blood*
  • Diabetes Mellitus, Type 1 / ethnology*
  • Female
  • Fructosamine / blood
  • Glycated Hemoglobin / metabolism*
  • Glycated Serum Albumin
  • Glycation End Products, Advanced
  • Humans
  • Male
  • Middle Aged
  • Prospective Studies
  • Serum Albumin / metabolism
  • United States
  • White People*
  • Young Adult


  • Blood Glucose
  • Glycated Hemoglobin A
  • Glycation End Products, Advanced
  • Serum Albumin
  • Fructosamine
  • Glycated Serum Albumin