Diagnosis of diabetes mellitus using HbA1c in Asians: relationship between HbA1c and retinopathy in a multiethnic Asian population

J Clin Endocrinol Metab. 2015 Feb;100(2):689-96. doi: 10.1210/jc.2014-2498. Epub 2014 Nov 6.


Context: Hemoglobin A1c (HbA1c) ≥ 6.5% (47.5 mmol/mol) has recently been included as a criterion for the diagnosis of diabetes mellitus. It is unclear whether this criterion is appropriate in Asians.

Objective: To examine the relationship between HbA1c and diabetes-specific moderate retinopathy in Asian ethnic groups.

Design, setting, and participants: Four independent population-based cross-sectional studies (2004-2011) in Singapore representing the three major Asian ethnic groups (n = 13 170 adults aged ≥ 25 y: Chinese, 5834; Malays, 3596; and Indians, 3740).

Main outcome: Moderate retinopathy was assessed from digital retinal photographs and defined as a level >43 using the Early Treatment Diabetic Retinopathy Study (ETDRS) scale. Sensitivity, specificity, positive and negative predictive values, and the area under the receiver operating characteristic curve for detecting moderate retinopathy were compared across ethnic groups at different HbA1c cut-points.

Results: HbA1c levels were higher in Indians and Malays compared to Chinese (P < .001). The prevalence of moderate retinopathy below HbA1c <6.5% was <1% in all ethnic groups. At HbA1c ≥ 6.5%, the sensitivity for detecting moderate retinopathy was lower in Chinese subjects compared to Indians and Malays (75.8 vs 86.0 and 85.3%), but specificity (89.7 vs 71.9 and 76.3%) was higher; however, positive predictive value and negative predictive value were similar among Chinese, Indians, and Malays (10.5, 12.3, 12.4%; and 99.6, 99.1, 99.2%, respectively). The AUCs were similar across all three ethnic groups (0.861, 0.851, and 0.853).

Conclusions: Our study supports the use of HbA1c for diagnosing diabetes in Asians. Despite some interethnic variation in the relationship of HbA1c and retinopathy, a cut-point of 6.5% performs reasonably well in the three major Asian ethnic groups.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Asian Continental Ancestry Group
  • Cross-Sectional Studies
  • Diabetes Mellitus / blood
  • Diabetes Mellitus / diagnosis*
  • Diabetes Mellitus / epidemiology
  • Diabetic Retinopathy / blood
  • Diabetic Retinopathy / diagnosis*
  • Diabetic Retinopathy / epidemiology
  • Ethnic Groups
  • Female
  • Glycated Hemoglobin A / analysis*
  • Humans
  • Male
  • Middle Aged
  • Prevalence
  • Sensitivity and Specificity
  • Singapore


  • Glycated Hemoglobin A
  • hemoglobin A1c protein, human