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Incidence and progression of diabetic retinopathy in a multi-ethnic US cohort: the Multi-Ethnic Study of Atherosclerosis
  1. Ning Cheung1,2,
  2. Miao Li Chee1,
  3. Ronald Klein3,
  4. Barbara E K Klein3,4,
  5. Steven Shea5,
  6. Mary Frances Cotch5,
  7. Ching-Yu Cheng1,2,
  8. Tien Yin Wong1,2
  1. 1Singapore Eye Research Insitute and Singapore National Eye Centre, Singapore
  2. 2Duke National University of Singapore Medical School, Singapore
  3. 3Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
  4. 4Departments of Medicine and Epidemiology, Vagelos College of Physicians & Surgeons and Mailman School of Public Health, Columbia University, New York City, New York, USA
  5. 5Division of Epidemiology and Clinical Applications, National Institutes of Health Intramural Research Program, National Eye Institute, National Institutes of Health, Bethesda, Maryland, USA
  1. Correspondence to Dr Ning Cheung, Singapore National Eye Centre, Singapore, Singapore; cheung.ning{at}


Aim To provide contemporary longitudinal data on the incidence and progression of diabetic retinopathy (DR) in a multi-ethnic population of whites, African Americans, Chinese and Hispanics in the United States.

Methods A prospective, multi-region, multi-ethnic population-based cohort study that included 498 participants with diabetes, aged 45–84 years at baseline, from the Multi-Ethnic Study of Atherosclerosis with retinal images obtained twice, on average 8 years apart. Presence and severity of DR were graded from these retinal images according to the modified Airlie House classification system. Main outcome measures were 8-year incidence, progression and improvement of DR, and their associated risk factors.

Results Over the 8 years, the cumulative rates were 19.2% for incident DR, 17.3% for DR progression, 23.3% for DR improvement, 2.7% for incident vision-threatening DR, 1.8% for incident proliferative DR and 2.2% for incident macular oedema. In multivariate analysis, significant risk factors associated with incident DR were higher glycosylated haemoglobin (relative risk (RR) 1.28; 95% CI: 1.16 to 1.41) and higher systolic blood pressure (RR 1.14; 95% CI: 1.04 to 1.25). Significant factors associated with DR progression were higher glycosylated haemoglobin (RR 1.20; 95% CI: 1.00 to 1.43) and higher low-density lipoprotein cholesterol (RR 1.01; 95% CI: 1.00 to 1.03).

Conclusion Over an 8-year period, approximately one in five participants with diabetes developed DR, while almost a quarter of those with DR at baseline showed improvement, possibly reflecting the positive impact of clinical and public health efforts in improving diabetes care in the United States over the last two decades.

  • retina
  • public health
  • epidemiology

Statistics from


  • Contributors NC contributed to data analysis and interpretation, initial drafting, critical review and final revision of the manuscript; MLC contributed to data analysis, critical review and final revision of the manuscript; RK, BEKK, SS, MFC and TYW contributed to securing funding and conducting the study, critical review and final revision of the manuscript; C-YC contributed to critical review and final revision of the manuscript.

  • Funding This research was supported by contracts N01‐HC‐95159, N01‐HC‐95160, N01‐HC‐95161, N01‐HC‐95162, N01‐HC‐95163, N01‐HC‐95164, N01‐HC‐95165, N01‐HC‐95166, N01‐HC‐95167, N01‐HC‐95168 and N01‐HC‐95169 from the National Heart, Lung, and Blood Institute at the National Institutes of Health. Support for the retinal component at the fifth MESA follow-up examination was provided by Intramural Research Award ZIAEY000403 by the National Eye Institute, National Institutes of Health.

  • Disclaimer The views expressed in this manuscript are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; the National Eye Institute; the National Institutes of Health; or the US Department of Health and Human Services.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Ethics approval The MESA cohort is being drawn from six regions in the United States: Baltimore City and Baltimore County, Maryland; Chicago, Illinois; Forsyth County, North Carolina; Los Angeles County, California; New York, New York; and St Paul, Minnesota. The institutional review boards of the six field centers have approved the study protocol. References: Bild DE, et al. Am J Epidemiol. 2002;156:871–81. No approval number or ID, but you can refer to references above or link below for detailed study protocol, which is public information (

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

  • Data availability statement Data are available upon reasonable request. Data are de-identified participant data from the Multi-Ethnic Study of Atherosclerosis. Approval was given to use these data from the study committee.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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