Article Text

Download PDFPDF

Role of socio-economic factors in visual impairment and progression of diabetic retinopathy
  1. Jin Rong Low1,
  2. Alfred Tau Liang Gan1,
  3. Eva K Fenwick1,2,
  4. Preeti Gupta1,
  5. Tien Y Wong1,2,3,
  6. Zhen Ling Teo1,
  7. Sahil Thakur1,
  8. Yih Chung Tham1,2,
  9. Charumathi Sabanayagam1,2,3,
  10. Ching-Yu Cheng1,2,3,
  11. Ecosse Luc Lamoureux1,2,3,
  12. Ryan Eyn Kidd Man1,2
  1. 1 Singapore Eye Research Institute, Singapore Eye Research Institute, Singapore
  2. 2 Duke-NUS Medical School, Singapore
  3. 3 National University of Singapore, Singapore
  1. Correspondence to Professor Ecosse Luc Lamoureux, Singapore Eye Research Institute, 20 College Road, The Academia, Discovery Tower Level 6, Singapore 169856, Singapore; ecosse.lamoureux{at}


Background To investigate the longitudinal associations between person-level and area-level socioeconomic status (PLSES and ALSES, respectively) with diabetic retinopathy (DR) and visual impairment (VI) in Asians with diabetes mellitus (DM).

Methods In this population-based cohort study, we included 468 (39.4%) Malays and 721 (60.6%) Indians with DM, with a mean age (SD) of 58.9 (9.1) years; 50.6% were female and the mean follow-up duration was 6.2 (0.9) years. Individual PLSES parameters (education, monthly income and housing type) were quantified using questionnaires. ALSES was assessed using the Socioeconomic Disadvantage Index derived from Singapore’s 2010 areal census (higher scores indicate greater disadvantage). Incident DR and VI were defined as absent at baseline but present at follow-up, while DR and VI progression were defined as a ≥1 step increase in severity category at follow-up. Modified Poisson regression analysis was used to determine the associations of PLSES and ALSES with incidence and progression of DR and VI, adjusting for relevant confounders.

Results In multivariable models, per SD increase in ALSES score was associated with greater DR incidence (risk ratio (95% CI) 1.27 (1.13 to 1.44)), DR progression (1.10 (1.00 to 1.20)) and VI incidence (1.10 (1.04 to 1.16)), while lower PLSES variables were associated with increased DR (low income: 1.68 (1.21 to 2.34)) and VI (low income: 1.44 (1.13 to 1.83); ≤4 room housing: 2.00 (1.57 to 2.54)) incidence.

Conclusions We found that both PLSES and ALSES variables were independently associated with DR incidence, progression and associated vision loss in Asians. Novel intervention strategies targeted at low socioeconomic status communities to decrease rates of DR and VI are warranted.

  • epidemiology

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Contributors TYW, C-YC, ECL, REKM designed the experiment. REKM, YCT, PG conducted the experiment. ATLG, REKM, JRL analysed/interpreted the data. TYW, C-YC provided the materials. JRL wrote the article. ATLG, EKF, PG, TYW, ZLT, ST, YCT, CS, C-YC, ECL, REKM proofed/revised the article.

  • Funding This study was supported by grants from the National Medical Research Council (STaR/0003/2008), the Singapore Bioimaging Consortium (C-011/2006) and the Biomedical Research Council (08/1/35/19/550).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study adhered to the principles of the Declaration of Helsinki. Approval was obtained from the SingHealth Institutional Review Board (#2010/392/A and 2012/487/A).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Due to Singaporean privacy laws, we are unable to upload participant data into a public repository. Anonymised data are however available upon request, subject to the corresponding author’s approval.

Linked Articles

  • At a glance
    Keith Barton James Chodosh Jost B Jonas