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New India-focused evidence is reigniting a global debate: the HbA1c test—widely regarded as the “gold standard” for diagnosing and monitoring diabetes—may misclassify blood sugar status in large populations where anaemia, hemoglobinopathies, and red-cell enzyme deficiencies are common.

That doesn’t mean the HbA1c test is “useless.” It means HbA1c can be highly reliable for many people—but not for everyone —and in India’s real-world conditions, relying on the HbA1c test alone may lead to delayed diagnosis, inaccurate risk estimates, and flawed public-health surveys.

What changed recently? A timeline of the fresh evidence

• Feb 8, 2026: A viewpoint in The Lancet Regional Health – Southeast Asia highlights “limitations and fallacies” of depending on HbA1c alone in South Asia—especially where anaemia and blood disorders are prevalent.
• Feb 9–10, 2026: Multiple Indian outlets report the same concern: HbA1c-based screening may misrepresent India’s diabetes burden and mislead individuals.

Why the HbA1c Test Can Mislead

HbA1c reflects average glucose exposure over ~2–3 months, but it also depends heavily on red blood cell (RBC) lifespan and hemoglobin characteristics.

1) Anaemia & altered RBC turnover

• If RBCs don’t live as long (hemolysis, some anaemias, blood loss), there’s less time for sugar to “stick” → HbA1c can read falsely low.
• In iron deficiency anaemia, HbA1c can be falsely high, and iron therapy may reduce HbA1c even without a major true glucose change.

2) Haemoglobin variants & assay interference

Some HbA1c testing methods are affected by haemoglobin variants; guidelines stress using variant-appropriate assays and interpreting results carefully.

3) India-specific risk: high prevalence of confounders

The 2026 Lancet viewpoint stresses that India has widespread anaemia and other RBC-related conditions, meaning a “one-test-fits-all” HbA1c approach can fail at scale.

“Is HbA1c Test no longer reliable?” Here’s the correct framing

HbA1c remains a cornerstone test—but major guidelines already acknowledge it can be unsuitable in certain conditions (notably anaemia, EPO treatment, hemodialysis, and some haemoglobin variant situations).

So the emerging message is not “discard HbA1c,” but “stop using HbA1c alone when confounders are likely.”

The alternatives doctors are considering (and when)

A) Plasma glucose–based confirmation (most important)

When HbA1c is suspected to be misleading, clinicians often lean on:

• Fasting Plasma Glucose (FPG)
• 75g Oral Glucose Tolerance Test (OGTT)

Guidelines emphasise diabetes can be diagnosed by A1c or plasma glucose criteria, and different tests can flag different people, especially near diagnostic thresholds.

B) Short-term glycemic markers (2–3 weeks)

• Fructosamine / Glycated Albumin (GA) may help in specific scenarios where HbA1c is distorted by RBC issues.

C) Continuous Glucose Monitoring (CGM) + SMBG

The new India-focused argument: use multi-parameter strategies—OGTT, SMBG/CGM where feasible—rather than HbA1c alone.

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HbA1c Test is valuable, but in anemia-heavy populations, HbA1c-only strategies can misclassify risk.

HbA1c Test