article · Nature Medicine
Fasting plasma glucose and haemoglobin A1c are standard tests for diagnosing diabetes, yet they often identify different individuals. An analysis of 117 population-based studies across different world regions revealed that the proportion of previously undiagnosed diabetes identified through screening ranged from 30% in high-income western regions to 66% in South Asia. Among individuals diagnosed through screening with either test, only 29% to 39% showed elevations in both markers, leaving most cases discordant. In most low- and middle-income regions, isolated elevated haemoglobin A1c occurred more frequently than isolated elevated fasting plasma glucose. Consequently, relying exclusively on fasting plasma glucose in these settings can delay diagnosis and underestimate overall diabetes prevalence. To address this disparity, mathematical prediction equations were formulated to estimate the likelihood of elevated haemoglobin A1c from fasting plasma glucose levels and vice versa.
Diabetes often remains undiagnosed, especially in lower-income regions where standard screening methods can miss cases. Because different diagnostic tests identify different patients, relying on a single measurement can skew public health estimates and delay essential treatment. Understanding these regional discrepancies ensures that healthcare systems select appropriate testing approaches and deploy diagnostic resources where they will detect the greatest number of cases.
The developed prediction equations offer an applied analytical tool for public health agencies, screening programmes, and healthcare planners. They can guide the targeted procurement and allocation of haemoglobin A1c tests where diagnostic funding is constrained. The work is at an applied research stage, ready to inform health economic models, screening guidelines, and diagnostic deployment strategies rather than representing an immediate standalone commercial product.
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Fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) are both used to diagnose diabetes, but these measurements can identify different people as having diabetes. We used data from 117 population-based studies and quantified, in different world regions, the prevalence of diagnosed diabetes, and whether those who were previously undiagnosed and detected as having diabetes in survey screening, had elevated FPG, HbA1c or both. We developed prediction equations for estimating the probability that a person without previously diagnosed diabetes, and at a specific level of FPG, had elevated HbA1c, and vice versa. The age-standardized proportion of diabetes that was previously undiagnosed and detected in survey screening ranged from 30% in the high-income western region to 66% in south Asia. Among those with screen-detected diabetes with either test, the age-standardized proportion who had elevated levels of both FPG and HbA1c was 29-39% across regions; the remainder had discordant elevation of FPG or HbA1c. In most low- and middle-income regions, isolated elevated HbA1c was more common than isolated elevated FPG. In these regions, the use of FPG alone may delay diabetes diagnosis and underestimate diabetes prevalence. Our prediction equations help allocate finite resources for measuring HbA1c to reduce the global shortfall in diabetes diagnosis and surveillance.
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DOI: 10.1038/s41591-023-02610-2
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