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CHAPTER 4.3

APPENDIX J: DIFFERENCES IN CLINICAL DIAGNOSIS AND
REQUIREMENT OF DIABETES

Prevention and treatment of diabetes entail policies and protocols that differ internationally
due to variances in epidemiology and demographic trends of health systems. Such variances
have implications on severity of disease and case definitions among populations.
Internationally, different professional health organisations such as the WHO, American
Diabetes Association (ADA), and Diabetes UK have similar guidelines as to which tests to use
for diagnosis and which referential systems of the different blood test result levels to adopt
for grading the disease severity of diabetes.

However, there are small but important differences on the range of diagnostic
criteria adopted by different institutions which have substantial implications on the number of
individuals detected with pre-diabetes and/or diabetes. For example, in comparing the ADA
criteria to the WHO criteria, we observe that the former has broader requirements for the
diagnosis of diabetes, with FPG concentrations of 5.6–6.9 mmol/L or HbA1c of 39–47
mmol/mol (5.7–6.4%), whereas WHO and the International Expert Committee recommend
an FPG cut off 6.0–6.9 mmol/L and HbA1c of 42–47 mmol/mol (6.0–6.4%). There is no
“one-size-fits-all” mantra as macro-contexts and healthcare challenges differ across
jurisdictions. Consequently, a variation of clinical cut-offs can be observed in international
practice, where a lower cut-off of 6.3% for HbA1c is recommended in Malaysia and a higher
cut-off of 6.7% is recommended in New Zealand. While in Singapore, the use of HbA1c for
diagnosis of diabetes is not recommended altogether (Lim et al., 2018).

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