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Logo of diacareAmerican Diabetes AssociationSubscribeSearchDiabetes Care Journal
Diabetes Care. 2013 February; 36(2): e23.
Published online 2013 January 17. doi:  10.2337/dc12-1135
PMCID: PMC3554279

Comment on: Hardikar et al. Spuriously High Prevalence of Prediabetes Diagnosed by HbA1c in Young Indians Partly Explained by Hematological Factors and Iron Deficiency Anemia. Diabetes Care 2012;35:797–802

We read with great interest the article by Hardikar et al. (1). In their epidemiological study in nondiabetic subjects, the authors observed an inverse association between HbA1c and hemoglobin levels, mean cell volume, and mean cell hemoglobin. In the multivariate models, laboratory parameters indicating iron deficiency anemia were negatively associated with HbA1c. On the basis of their study, Hardikar et al. support the notion that iron deficiency contributes to an increased erythrocyte survival and a falsely elevated HbA1c in subjects with similar degrees of glycemia. These data seem to be in contradiction with experimental studies showing that anemia in patients with iron deficiency is not only the result of an ineffective erythropoiesis but is also explained by a decreased erythrocyte life span (2,3) due to an increased programmed cell death (eryptosis) with enhanced removal of erythrocytes from the circulation (4). In the light of these experimental studies, it would have been more informative if data on erythrocyte production, as reflected by the reticulocyte count, and the degree of hemoglobinization of erythrocytes and reticulocytes were provided (5).

The higher HbA1c results in subjects with iron deficiency anemia are more likely due to a relative survival of previously formed noniron-deficient erythrocytes with a relatively higher level of glycation and a decreased survival of younger erythrocytes with a lower degree of glycation. These assumptions should be investigated in longitudinal studies assessing the rate of glycation in relation to erythrocyte life span and survival.


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


1. Hardikar PS, Joshi SM, Bhat DS, et al. Spuriously high prevalence of prediabetes diagnosed by HbA1c in young Indians partly explained by hematological factors and iron deficiency anemia. Diabetes Care 2012;35:797–802 [PMC free article] [PubMed]
2. Loría A, Sánchez-Medal L, Lisker R, De Rodríguez E, Labardini J. Red cell life span in iron deficiency anaemia. Br J Haematol 1967;13:294–302 [PubMed]
3. Sánchez-Medal L, Loria A. Erythrocyte production in iron deficiency anemia. Acta Haematol 1996;96:146–149 [PubMed]
4. Kempe DS, Lang PA, Duranton C, et al. Enhanced programmed cell death of iron-deficient erythrocytes. FASEB J 2006;20:368–370 [PubMed]
5. Bartels PC, Schoorl M, Schoorl M. Hemoglobinization and functional availability of iron for erythropoiesis in case of thalassemia and iron deficiency anemia. Clin Lab 2006;52:107–114 [PubMed]

Articles from Diabetes Care are provided here courtesy of American Diabetes Association