Ethnic Differences in the Prevalence and Risk Factors of Diabetic Retinopathy: The Singapore Epidemiology of Eye Diseases Study

doi:10.1016/j.ophtha.2017.10.026

Ophthalmology

Volume 125, Issue 4, April 2018, Pages 529-536

https://doi.org/10.1016/j.ophtha.2017.10.026 Get rights and content

Purpose

To evaluate the prevalence and risk factors for diabetic retinopathy (DR) in the Singapore Epidemiology of Eye Diseases (SEED) Study.

Design

Population-based, cross-sectional study.

Participants

Persons of Malay, Indian, and Chinese ethnicity aged 40+ years, living in Singapore.

Methods

Diabetes was defined as nonfasting plasma glucose ≥200 mg/dl (11.1 mmol/l), glycated hemoglobin A1c (HbA1c) >6.5%, self-reported physician-diagnosed diabetes, or the use of glucose-lowering medication. Retinal photographs, were graded for the presence and severity of DR using the modified Airlie House classification system.

Main Outcome Measures

Diabetic retinopathy, diabetic macular edema (DME), vision-threatening diabetic retinopathy (VTDR), defined as the presence of severe nonproliferative or proliferative DR, or clinically significant macular edema (CSME).

Results

Of the 10 033 subjects, 2877 (28.7%) had diabetes and gradable photographs for analysis. The overall age-standardized prevalence (95% confidence interval [CI]) was 28.2% (25.9–30.6) for any DR, 7.6% (6.5–9.0) for DME, and 7.7% (6.6–9.0) for VTDR. Indians had a higher prevalence of any DR (30.7% vs. 26.2% in Chinese and 25.5% in Malays, P = 0.012); a similar trend was noted for any DME (P = 0.001) and CSME (P = 0.032). Independent risk factors for any DR were Indian ethnicity (odds ratio [OR], 1.41; 95% CI, 1.09–1.83, vs. Chinese), diabetes duration (OR, 1.10; 95% CI, 1.08–1.11, per year), HbA1c (OR, 1.25; 95% CI, 1.18–1.32, per %), serum glucose (OR, 1.03; 95% CI, 1.00–1.06, per mmol/l), and systolic blood pressure (OR, 1.14; 95% CI, 1.09–1.19, per 10 mmHg). Diastolic blood pressure (OR, 0.74; 95% CI, 0.65–0.84, per 10 mmHg increase), total cholesterol (OR, 0.87; 95% CI, 0.80–0.95, per mmol/l increase), and low-density lipoprotein (LDL) cholesterol (OR, 0.83; 95% CI, 0.74–0.92, per mmol/l increase) were associated with lower odds of any DR. Risk factors were largely similar across the 3 ethnic groups.

Conclusions

Indian Singaporeans have a higher prevalence of DR and DME compared with Chinese and Malays. Major risk factors for DR in this study were similar across the 3 ethnic groups. Addressing these risk factors may reduce the impact of DR in Asia, regardless of ethnicity.

Section snippets

Study Design and Population

The Singapore Epidemiology of Eye Diseases (SEED, 2004–2011) Study is a population-based study that included 3 major ethnic groups in Singapore: Malays (2004–2006), Indians (2007–2009), and Chinese (2009–2011).16, 17 The study adhered to the Declaration of Helsinki, and ethics approval was obtained from the Singapore Eye Research Institute Institutional Review Board. On the basis of an age-stratified random sampling strategy, 5000 Malays, 6350 Indians, and 6752 Chinese names were selected. Of

Results

Of the total of 10 033 persons who participated in SEED, 2964 had diabetes. After excluding those with ungradable photographs (n = 87, 2.9%), 2877 persons with diabetes (1008 Malays, 1288 Indians, 581 Chinese) were included for the final analysis. Of these, 51 (1.7%) had type 1 diabetes and the rest had type 2 diabetes.

The age-standardized prevalence was 28.2% (95% CI, 25.9–30.6) for any DR, 7.6 (95% CI, 6.5–9.0) for any DME, 7.7% (95% CI, 6.6–9.0) for VTDR, and 6.4% (95% CI, 5.4–7.6) for CSME.

Discussion

In this study of a multi-ethnic Asian population aged 40 to 80+ years with diabetes, we showed that 1 in 3 had DR, and 1 in 10 had vision-threatening levels of DR. The lower prevalence of diabetes in Chinese is consistent with the findings of 2 previous studies. The Singapore National Health Survey found that the prevalence of diabetes in adults aged 18 to 69 years was 15.3% in Indians, 11.0% in Malays, and 7.1% in Chinese.²³ Likewise, in the Singapore Prospective Study Program, among an older

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To evaluate the associations of blood pressure levels with diabetic retinopathy (DR), proliferative diabetic retinopathy (PDR) and diabetic macular edema (DME) in patients with diabetes mellitus.
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A total of 152,844 patients with diabetes from 90 major cities in 19 provincial regions of mainland China during 2018–2021 were finally recruited.
Blood pressure was graded into 5 levels: normal (without hypertension and <120/80 mmHg), normal high (without hypertension and ≥120/80 mmHg), HT-intensive (hypertension and <120/80 mmHg), HT-moderate (hypertension and blood pressure between 120/80 mmHg and 140/90 mmHg) and HT-high (hypertension and ≥140/90 mmHg). Logistic regression was employed to verify the associations of hypertension and blood pressure levels with DR, PDR and DME. The impacts of blood pressure levels on the outcomes were qualified with nomogram models.
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There were 16,685 (10.92%) participants having DR, 2841 (1.86%) having PDR, and 1566 (1.02%) having DME. There were 8126 (5.32%) patients without hypertension and 1350 (0.88%) patients with hypertension having blood pressure <120/80 mmHg. When compared to the normal group with covariates adjusted, an increased prevalence of DR was observed in normal high (adjusted odds ratio [OR] = 1.114, 95% confidence interval [CI] = 1.033–1.202), HT-moderate (adjusted OR = 1.163, 95% CI = 1.065–1.271), and HT-high (adjusted OR = 1.203, 95% CI = 1.114–1.300).
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: We accrued a cohort of 226 eyes with DR consisting of 51 East Asian eyes, 102 South Asian eyes, 30 Caucasian eyes, and 43 Latino eyes, all evaluated with ultrawide field pseudocolor images. Images were manually annotated for DR lesions and were classified as having predominantly peripheral lesions (PPL) or predominantly central lesions (PCL) using 4 quantitative methods. The percent distribution of PCL to PPL was compared among different ethnicities.
Using a single-field lesion frequency-based method, East Asian eyes more frequently demonstrated a PPL distribution (86.3%), whereas South Asian eyes more frequently demonstrated a PCL distribution (64.7%). These findings were also observed when considering only the subset of treatment-naïve eyes. Furthermore, in treatment-naïve eyes without proliferative DR, the percent distribution of PPL to PCL in East Asian eyes was significantly different when compared to other ethnicities (P < .0001 South Asian, P = .035 Caucasian, P = .0003 Latino). The majority of patients (60%-78%) in all ethnic groups had moderate nonproliferative diabetic retinopathy(NPDR), and the same difference between East Asian and South Asian eyes was observed in this subgroup.
The distribution of DR lesions appears to vary among different ethnicities. DR lesions tend to be distributed more peripherally in East Asian eyes compared to other ethnic groups, particularly South Asian eyes, which tend to have more central disease. The prognostic implications of these ethnic differences in DR lesion distribution require further investigation.
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: Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

: Funded by the National Medical Research Council (grants 0796/2003, IRG07nov013, IRG09nov014, STaR/0003/2008; CG/SERI/2010) and Biomedical Research Council (grants 08/1/35/19/550, 09/1/35/19/616), Singapore. The sponsor or funding organization had no role in the design or conduct of this research.

: HUMAN SUBJECTS: Study protocol was approved by IRB/ethics committee of the Singapore Eye Research Institute Institutional Review Board. All studies adhered to the tenets of the Declaration of Helsinki.

: Author Contributions:

: Conception and design: Tan, Gan, Sabanayagam, Mitchell, Wang, Lamoureux, Cheng, Wong

: Data collection: Tan, Gan, Sabanayagam, Tham, Neelam, Mitchell, Cheng

: Analysis and interpretation: Tan, Gan, Sabanayagam, Tham, Cheng, Wong

: Overall responsibility: Tan, Gan, Sabanayagam, Tham, Neelam, Mitchell, Wang, Lamoureux, Cheng, Wong

View full text

Original articleEthnic Differences in the Prevalence and Risk Factors of Diabetic Retinopathy: The Singapore Epidemiology of Eye Diseases Study

Purpose

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Section snippets

Study Design and Population

Results

Discussion

Lancet

Diabetes Res Clin Pract

Surv Ophthalmol

Ophthalmology

Ophthalmology

Ophthalmology

Endocr Pract

Ophthalmology

Overview of epidemiologic studies of diabetic retinopathy

Ophthalmic Epidemiol

Diabetic retinopathy

Nat Rev Dis Primers

Diabetes in Asia: epidemiology, risk factors, and pathophysiology

JAMA

Prevalence and control of diabetes in Chinese adults

JAMA

Ten emerging trends in the epidemiology of diabetic retinopathy

Ophthalmic Epidemiol

Global prevalence and major risk factors of diabetic retinopathy

Diabetes Care

Higher prevalence of retinopathy in diabetic patients of South Asian ethnicity compared with white Europeans in the community: a cross-sectional study

Diabetes Care

Diabetic retinopathy in a multi-ethnic cohort in the United States

Am J Ophthalmol

Prevalence of and risk factors for diabetic macular edema in the United States

JAMA Ophthalmol

Is the risk of diabetic retinopathy greater in non-Hispanic blacks and Mexican Americans than in non-Hispanic whites with type 2 diabetes? A U.S. population study

Diabetes Care

No ethnic differences in the association of glycated hemoglobin with retinopathy: the National Health and Nutrition Examination Survey 2005-2008

Diabetes Care

Original article
Ethnic Differences in the Prevalence and Risk Factors of Diabetic Retinopathy: The Singapore Epidemiology of Eye Diseases Study