Ann Lab Med 2019; 39(2): 209-213
Hemoglobin A1c Levels Are Slightly but Significantly Lower in Normoglycemic Subjects With the Hemoglobin E Phenotype
Busadee Pratumvinit, M.D.1*, Kanit Reesukumal, M.D.1, Sithikan Hanyongyuth, B.P.H.1, Sujitra Wangchaijaroenkit, B.Sc.1, Julaporn Pooliam, M.Sc.2, Gerald J. Kost, M.D. Ph.D3, Panumas Kamkang, B.Sc.1, and Tze Ping Loh, M.D.4

1Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

2Division of Clinical Epidemiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

3Point-of-Care Testing Center for Teaching and Research (POCT·CTR), School of Medicine, University of California, Davis, California, USA.

4Department of Laboratory Medicine, National University Hospital, Singapore.

Corresponding author: Busadee Pratumvinit, M.D. Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University 2 Wang Lang Road, Bangkok Noi, Bangkok 10700, Thailand. Tel/Fax: +662-418-1367,
Received: January 29, 2018; Revised: April 13, 2018; Accepted: October 12, 2018; Published online: November 13, 2018.
© Korean Society for Laboratory Medicine. All rights reserved.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Hb mutations can alter the structure, behavior, stability, or quantity of the globin chain produced. Some Hb variants shorten the erythrocyte life span, resulting in physiologically lower hemoglobin A1c (HbA1c) levels. The hemoglobin E (HbE) phenotype involves a single-nucleotide polymorphism that reduces β-globin chain synthesis. We compared the HbA1c levels of subjects with normal Hb (HbAA; N=131) and HbE (N=148) phenotypes, examining potential hematological and biochemical factors contributing to differences in HbA1c levels. All had normal fasting plasma glucose (<5.6 mmol/L), AST, ALT, and creatinine levels. Mean±SD HbA1c levels differed between HbAA and HbE subjects: 5.5±0.3% and 5.3±0.3% (P<0.001) according to an immunoassay, and 5.5±0.3% and 5.3±0.3% (P<0.001) according to cation-exchange HPLC, respectively. In multiple logistic regression, only mean corpuscular volume (P<0.001) contributed to the difference in HbA1c levels between groups. Although a 0.2% difference in HbA1c is relatively small and unlikely to alter clinical decisions, epidemiologically, this can lead to misclassification of a significant proportion of the population, especially since the threshold of non-diabetes HbA1c (≤5.6%) falls very close to the HbA1c median of the general population.

Keywords: Hemoglobin A1c, Hemoglobin E, HPLC, Immunoassay

The utility of hemoglobin A1c (HbA1c) as a reliable reflection of the long-term glycemic index in clinical practice is premised upon a normal hemoglobin (Hb) glycation rate [1, 2]. This requires a relatively stable glycemic environment in vivo and erythrocyte turnover. However, several biological factors that significantly alter the glycation rate, such as a rapidly changing glycemic status or altered erythrocyte life span, may limit the validity of this assumption and the reliability of HbA1c as a biomarker [3]. Hb variants result from a mutated globin chain of the Hb molecule, which can alter the structure, behavior, stability, or quantity of the globin chain produced [4, 5]. Some Hb variants (e.g., sickle cell) shorten the erythrocyte life span due to structural instability [4, 5], resulting in a physiologically lower HbA1c level for a given glycemic status [6].

The hemoglobin E (HbE) phenotype results from a single-nucleotide polymorphism that reduces synthesis of β-globin chain [6, 7]. However, the impact of HbE phenotype on the life span of erythrocytes is currently unknown. HbE is one of the most common Hb variants globally, particularly in South and Southeast Asia [8]. HbE can interfere with HbA1c measurement in some laboratory methods [9, 10, 11, 12]. Paisooksantivatana et al. [13] showed that HbA1c levels are lower in HbE subjects than those with normal Hb (HbAA), but they did not control for age and glycemic status, both of which can significantly affect HbA1c levels. Therefore, we compared the HbA1c levels of normoglycemic HbAA and HbE subjects, controlling for age, and examined potential hematological and biochemical factors contributing to the differences in HbA1c levels.

In this cross-sectional case-control study, subjects were prospectively recruited among those visiting the clinics at Siriraj Hospital, Mahidol University, Bangkok, Thailand, for regular health screening between December 2014 and March 2016. All subjects were otherwise asymptomatic. This study was approved by the Siriraj Hospital Institutional Review Board (Ref: Si718/2014), which waived the requirement for informed consent.

Subjects fasted for 10–12 hours before standard phlebotomy. Plasma samples were collected in lithium heparinized and sodium fluoride (for glucose) tubes, transported to the laboratory, centrifuged at 2,136×g for seven minutes, and analyzed. Whole blood samples were collected in EDTA vacutainers. We used anonymized, residual blood samples of subjects with normal fasting plasma glucose (FPG, <5.6 mmol/L), AST, ALT, and creatinine levels (i.e., results falling within the laboratory reference intervals: AST 0–0.67 µkat/L in males, 0–0.53 µkat/L in females; ALT 0–0.68 µkat/L in males, 0–0.55 µkat/L in females; creatinine 59–103 µmol/L in males, 45–84 µmol/L in females). Tests for FPG, AST, ALT, creatinine, total cholesterol, HDL-cholesterol, and triglycerides were performed using the Roche cobas 8000 analyzer (Roche Diagnostics, Mannheim, Germany). LDL-cholesterol was calculated using the Friedewald formula [14]. Complete blood count was obtained using the XN-10 (Sysmex Corporation, Kobe, Japan) or Beckman Coulter LH 780 (Beckman Coulter, Miami, FL, USA) analyzer. HbA1c level was measured in K2EDTA whole blood samples using both an immunoassay (Integra 800 CTS, Roche Diagnostics; between-run CV: 1.8%) and cation-exchange HPLC (D-10 Dual Extended Program, Bio-Rad Laboratories, Hercules, CA, USA; between-run CV: 2.4%). Samples were analyzed by two HbA1c methods within eight hrs of each other and stored at 4℃ in the meantime as the HbA1c level is generally stable for up to one week at 2–8℃ [15]. These HbA1c laboratory methods have been validated to not be influenced by the HbE phenotype (

HbAA status was determined on the basis of a mean corpuscle volume (MCV) of >80 fL and a normal Hb chromatogram with a Hb alpha 2 (HbA2)/E area <3.5% on the D-10 analyzer. HbE subjects were identified by the presence of an A2/E window with an area of 25–35% according to the local clinical practice guidelines for diagnosis and management of thalassemia syndromes [16]. Subjects with HbE disease (homozygous for the HbE allele) were excluded due to the absence of an HbA0 peak on the chromatogram.

An unpaired t-test was used to compare HbA1c levels between HbAA and HbE subjects since HbA1c was normally distributed in each group according to the histogram. The difference in HbA1c levels between two analyses was normally distributed; therefore, a paired t-test was employed for its analysis. A chi-square test was used to compare the sex ratio. To identify factors contributing to differences in HbA1c levels between groups, a univariate binary logistic regression was first performed, followed by a multiple logistic regression using variables with P<0.2 in the univariate analysis. Multicollinearity was tested using a variance inflation factor (VIF) of <10. Results from binary logistic regression were presented as odds ratios (ORs) and 95% confidence intervals (CIs). A Bland-Altman plot was constructed to assess whether the difference in HbA1c levels obtained by the two methods depended on the “true” (i.e., average) value. Statistical analyses were performed using PASW version 18.0 (SPSS Inc., Chicago, IL, USA) and MedCalc version 16 (MedCalc, Mariakerke, Belgium). P value of <0.05 was considered statistically significant. To determine clinical significance, we used the allowable total analytic error for HbA1c by the College of American Pathologist proficiency testing program, which is currently±6% of an accurately assigned value [17].

In total, 131 HbAA subjects and 148 HbE subjects were included; age (43.3±9.6 years for HbAA and 41.5±9.7 years for HbE, P=0.12) and sex (male 16.0% for HbAA and 16.9% for HbE; P=0.85) did not differ between groups. Subjects' hematological and biochemical data are summarized in Table 1. Among the HbE subjects, 131/148 (88.5%) had a low MCV (62.5–79.9 fL), and the remaining had low to normal MCV (80.1–83.2 fL).

The mean±SD (range) HbA1c levels of HbAA and HbE subjects were 5.5±0.3% (4.5–6.3%) and 5.3±0.3% (4.4–6.6%), respectively, according to the immunoassay, and were 5.5±0.3% (4.4–6.4%) and 5.3±0.3% (4.5–6.1%), respectively, according to HPLC (Figs. 1 and 2; P<0.001 for both methods).

In the univariate logistic regression, there were no differences in FPG, total cholesterol, triglycerides, HDL-cholesterol, calculated LDL-cholesterol, or creatinine levels between HbAA and HbE subjects (P>0.05 for all). AST, ALT, Hb, Hct, MCV, mean corpuscular Hb, and mean corpuscular Hb concentration significantly differed between HbAA and HbE subjects. In the multiple logistic regression, only MCV significantly contributed to differences in HbA1c levels between groups (Table 1).

Paisooksantivatana et al. [13] suggested that the difference in HbA1c levels between HbAA and HbE subjects in their study was related to biological factors. However, their ability to draw this conclusion is limited because the glycemic status of their subjects was neither defined a priori nor described in their study. They also did not specify the age of their subjects, which is associated with increasing HbA1c levels [18]. We selected subjects with normal FPG, AST, ALT, and creatinine levels to control biological factors that may confound the interpretation of HbA1c results. Moreover, age did not significantly differ between the two groups. The HbA1c level was slightly, but significantly, lower (mean difference of 0.2% HbA1c, or mean % difference of 3.6%) in HbE subjects than in HbAA subjects, according to both the immunoassay and HPLC. Our finding is similar to that of Paisooksantivatana et al . [13], albeit at a smaller magnitude. This discrepancy may be explained by the more stringent inclusion criteria used in our study. Interestingly, the magnitude of the difference in HbA1c levels matches that of the racial difference in HbA1c levels between non-Hispanic White (median: 4.9%), non-Hispanic Black (median: 5.2%), and Mexican-American (median: 5.0%) children and young adults included in the Third National Health and Nutrition Examination Survey of the USA [19].

Although the difference in HbA1c levels between normoglycemic HbAA and HbE subjects is relatively small and unlikely to alter clinical decisions, from an epidemiological perspective, a 0.2% HbA1c difference can lead to a significant proportion of population being classified differently. This is because the threshold of non-diabetes HbA1c (≤5.6%) falls very close to the mean or median of the distribution of HbA1c in the general population (e.g., mean of 5.47% in Thailand [20], median of 5.5–5.9% in Singapore [18]). Hence, even a relatively small shift in HbA1c levels can lead to a significant proportion of the population being misclassified.

A limitation of this study is that HbA1c level was measured in only normoglycemic subjects, to control glycemic status. The physiological effects of HbE on HbA1c levels in subjects with impaired glucose metabolism or diabetes are unknown and should be explored. Another limitation is the lack of definitive Hb testing (e.g., genetic analysis) to confirm the identity of the Hb variants, owing to resource limitations. Importantly, the finding that MCV significantly contributes to the difference in HbA1c levels between HbAA and HbE subjects may be due to a selection bias, as HbAA was defined as MCV >80 fL, according to the local clinical practice guidelines for diagnosis and management of thalassemia syndrome [16]. Thus, this finding should be interpreted with caution and warrants further research.

In conclusion, while controlling age and glycemic status, we showed that HbA1c level is slightly but significantly lower in HbE subjects than HbAA subjects. Each laboratory should compile a database of subjects with hemoglobinopathy and provide interpretative comments to inform clinicians when hemoglobinopathy is identified in samples for HbA1c measurement. Clinicians should exercise caution when interpreting HbA1c results from HbE subjects.

Authors' Disclosures of Potential Conflicts of Interest

No potential conflicts of interest relevant to this article were reported.


We thank Bio-Rad Laboratories and Roche Diagnostics for reagent supplies and technical advice. Kunatip Sutthiyuth provided invaluable assistance with graphics. Busadee Pratumvinit and Kanit Reesukumal each received a Chalermprakiat grant from the Faculty of Medicine Siriraj Hospital, Mahidol University. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Fig. 1.

Histogram of HbA1c results in the study population. (A) and (B) show HbA1c levels measured by the Roche Integra 800CTS immunoassay (Roche Diagnostics, Mannheim, Germany). (C) and (D) show HbA1c levels measured by Bio-Rad D10 HPLC (Bio-Rad Laboratories, Hercules, CA, USA).

Fig. 2.

Bland-Altman plots of HbA1c results for HbAA and HbE subjects. (A) and (B) show the absolute differences in HbA1c results between the immunoassay (Roche Integra 800CTS; Roche Diagnostics, Mannheim, Germany) and cation-exchange HPLC (Bio-Rad D-10; Bio-Rad Laboratories, Hercules, CA, USA). (C) and (D) show percentage of the mean differences in HbA1c results. Left panels are for HbAA subjects (N=131) and right panels are for HbE subjects (N=148). The bold solid lines denote mean bias and 95% confidence intervals. The dashed lines denote the 95% limits of agreement of the difference, and the dotted lines denote the College of American Pathologists allowable total error (TEa, ±6%) [17].


Factors associated with differences in HbA1c levels between HbAA (N=131) and HbE (N=148) subjects

FactorsHbAA (mean±SD)HbE (mean±SD)Univariate analysisMultivariate analysis
Crude OR (95% CI)PAdjusted OR (95% CI)P
FPG (mmol/L)4.90 ± 0.304.80 ± 0.400.67 (0.33–1.35)0.260--
Total cholesterol (mmol/L)5.40 ± 0.905.20 ± 0.800.80 (0.61–1.05)0.1000.60 (0.29–1.24)0.17
Triglycerides (mmol/L)1.10 ± 0.601.10 ± 0.600.91 (0.61–1.36)0.660--
HDL-cholesterol (mmol/L)1.70 ± 0.401.70 ± 0.401.04 (0.61–1.76)0.890--
LDL-cholesterol (mmol/L)3.20 ± 0.903.10 ± 0.800.78 (0.58–1.04)0.090--
Creatinine (μmol/L)67.20 ± 11.8066.70 ± 12.101.00 (0.98–1.02)0.710--
AST (μkat/L)0.32 ± 0.070.30 ± 0.070.01 (0.00–0.41)0.010--
ALT (μkat/L)0.28 ± 0.120.25 ± 0.110.11 (0.01–0.87)0.0400.00 (0.00–5.57)0.14
Hemoglobin (g/L)132.80 ± 10.60125.50 ± 10.200.93 (0.91–0.96)< 0.0010.99 (0.93–1.06)0.83
Hematocrit (L/L)0.41 ± 0.030.39 ± 0.030.2 × 10-8 (0.7 × 10-12-0.9 × 10-5)< 0.001--
MCV (fL)88.00 ± 4.4076.90 ± 3.100.27 (0.17–0.42)< 0.0010.25 (0.16–0.41)< 0.001
MCH (fmol/cell)1.77 ± 0.101.53 ± 0.080.2 × 10-17 (0.2 × 10-22-0.2 × 10-12)< 0.001--
MCHC (mmol/L)20.10 ± 0.5019.90 ± 0.400.44 (0.25–0.75)0.003--

Abbreviations: HbAA, normal hemoglobin; HbA1c, hemoglobin A1c; HbE, hemoglobin E; OR, odds ratio; CI, confidence interval; FPG, fasting plasma glucose; MCV, mean corpuscular volume; MCH, mean corpuscular Hb; MCHC, mean corpuscular Hb concentration.

  1. Borg R, Kuenen JC, Carstensen B, Zheng H, Nathan DM, Heine RJ, et al. Associations between features of glucose exposure and A1C: the A1C-Derived Average Glucose (ADAG) study. Diabetes 2010;59:1585-1590.
  2. Loh TP, Sethi SK, Wong MS, Tai ES, Kao SL. Relationship between measured average glucose by continuous glucose monitor and HbA1c measured by three different routine laboratory methods. Clin Biochem 2015;48:514-518.
  3. American Diabetes Association. 2. Classification and diagnosis of diabetes: standards of medical care in Diabetes-2018. Diabetes Care 2018;41:S13-S27.
  4. Forget BG, Bunn HF. Classification of the disorders of hemoglobin. Cold Spring Harb Perspect Med 2013;3:a011684.
  5. Kohne E. Hemoglobinopathies: clinical manifestations, diagnosis, and treatment. Dtsch Arztebl Int 2011;108:532-540.
  6. Rhea JM, Molinaro R. Pathology consultation on HbA(1c) methods and interferences. Am J Clin Pathol 2014;141:5-16.
  7. Vichinsky E. Hemoglobin E syndromes. Hematology Am Soc Hematol Educ Program 2007;:79-83.
  8. Modell B, Darlison M. Global epidemiology of haemoglobin disorders and derived service indicators. Bull World Health Organ 2008;86:480-487.
  9. Little RR, Rohlfing CL, Hanson S, Connolly S, Higgins T, Weykamp CW, et al. Effects of hemoglobin (Hb) E and HbD traits on measurements of glycated Hb (HbA1c) by 23 methods. Clin Chem 2008;54:1277-1282.
  10. Sthaneshwar P, Shanmugam H, Swan VG, Nasurdin N, Tanggaiah K. Effect of HbE heterozygosity on the measurement of HbA1c. Pathology 2013;45:417-419.
  11. Azizi A, Sthaneshwar P, Shanmugam H, Arumugam S. Effect of HbE trait on measurement of HbA1c by three different methods. Pathology 2015;47:495-497.
  12. Loh TP, Cheng WL, Kao SL, Thai AC, Sethi SK. Effects of haemoglobin E traits on HbA1c measurement by two cation-exchange HPLC and two immunoturbidimetric methods. Pathology 2014;46:265-266.
  13. Paisooksantivatana K, Kongsomgan A, Banyatsuppasin W, Khupulsup K. Influence of hemoglobin E on measurement of hemoglobin A1c by immunoassays. Diabetes Res Clin Pract 2009;83:e84-e85.
  14. Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem 1972;18:499-502.
  15. Weykamp C. HbA1c: a review of analytical and clinical aspects. Ann Lab Med 2013;33:393-400.
  16. Fucharoen S, Tanphaichitr V, Torcharus K, Viprakasit V, Meekaewkunchorn A. Clinical practice guidelines for diagnosis and management of thalassemia syndromes. Bangkok: PALiving; 2014:9-18.
  17. Little RR, Rohlfing CL. Assessing quality from an accuracy-based HbA1c proficiency survey. Clin Chem Lab Med 2016;54:e75-e76.
  18. Loh TP, Ma S, Heng D, Khoo CM. Age-related changes in the cardiometabolic profiles in Singapore resident adult population: findings from the National Health survey 2010. PLoS One 2016;11:e0162102.
  19. Saaddine JB, Fagot-Campagna A, Rolka D, Narayan KM, Geiss L, Eberhardt M, et al. Distribution of HbA(1c) levels for children and young adults in the U.S.: third National Health and Nutrition Examination Survey. Diabetes Care 2002;25:1326-1330.
  20. Charuruks N, Milintagas A, Watanaboonyoungcharoen P, Ariyaboonsiri C. Determination of reference intervals of HbA1c (DCCT/NGSP) and HbA1c (IFCC) in adults. J Med Assoc Thai 2005;88:810-816.

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