Should the hemoglobin A1c diagnostic cutoff differ between blacks and whites? A cross-sectional study

Ann Intern Med. 2012 Aug 7;157(3):153-9. doi: 10.7326/0003-4819-157-3-201208070-00004.


Background: Hemoglobin A1c (HbA1c) levels are known to be consistently higher in black persons than in white persons at any given glycemic level. Whether the optimal diagnostic threshold of HbA1c should differ between blacks and whites is unclear.

Objective: To compare the relationships between HbA1c level and the prevalence of retinopathy in black and white U.S. adults.

Design: Cross-sectional study.

Setting: A nationally representative sample of the National Health and Nutrition Examination Survey from 2005 through 2008.

Patients: 2804 white persons and 1008 black persons aged 40 years or older in the United States.

Measurements: Prevalence of retinopathy. Logistic regression models and restricted cubic spline models were constructed separately for white and black populations to test the HbA1c levels at which risk for retinopathy begins to increase.

Results: After adjustment for age, sex, hypertension, body mass index, family history of diabetes, and use of antidiabetes medications or insulin, the lowest HbA1c category for which the prevalence of retinopathy was significantly higher than the reference category (<5.5%) was 6.0% to 6.4% for white persons (risk difference, 4.8% [95% CI, 0.5% to 9.1%]) and 5.5% to 5.9% for black persons (risk difference, 5.3% [CI, 1.0% to 9.5%]). The restricted cubic spline models indicated that the risk for retinopathy increased at lower HbA1c levels in black persons than in white persons.

Limitation: The cross-sectional design of the study precluded examining the effect of the duration at each HbA1c level.

Conclusion: The prevalence of retinopathy begins to increase at a lower HbA1c level in black Americans than in white Americans. The findings do not support increasing the diagnostic threshold of HbA1c in black persons.

Primary funding source: None.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • African Continental Ancestry Group*
  • Blood Glucose / metabolism
  • Cross-Sectional Studies
  • Diabetic Retinopathy / blood
  • Diabetic Retinopathy / diagnosis*
  • Diabetic Retinopathy / ethnology*
  • European Continental Ancestry Group*
  • Female
  • Glycated Hemoglobin A / analysis
  • Glycated Hemoglobin A / metabolism*
  • Humans
  • Logistic Models
  • Male
  • Middle Aged
  • Nutrition Surveys
  • Prevalence
  • Risk Assessment
  • United States / epidemiology


  • Blood Glucose
  • Glycated Hemoglobin A