Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 1673
  • Home
  • Print this page
  • Email this page

   Table of Contents      
SYMPOSIUM - DR IN INDIA
Year : 2016  |  Volume : 64  |  Issue : 1  |  Page : 50-54

Diabetic care initiatives to prevent blindness from diabetic retinopathy in India


1 Indian Institute of Public Health, Public Health Foundation of India; Department of Clinical Research, Public Health Eye Care and Disability, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
2 L. V. Prasad Eye Institute, Hyderabad, Telangana, India

Date of Submission04-Nov-2015
Date of Acceptance14-Nov-2015
Date of Web Publication7-Mar-2016

Correspondence Address:
GVS Murthy
Indian Institute of Public Health, Public Health Foundation of India, ANV Arcade, 1 Amar Cooperative Society, Kavuri Hills, Madhapur, Hyderabad - 500 033, Telangana, India

Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0301-4738.178152

Rights and Permissions
  Abstract 

It is estimated that 65 million (17%) of 382 million persons with diabetes mellitus (DM) globally reside in India. While globally 35% persons with DM have diabetic retinopathy (DR), this proportion is reportedly lower in India, other countries in South Asia and China. We reviewed published data from 2008 onwards from PubMed, which ascertained DR in population-based representative samples. We also reviewed the risk factors for DR, on awareness regarding eye complications and on accessing an eye examination. Thirteen research studies have reported on the prevalence of DR among persons with DM; this prevalence was lower than the global level in China, India, and Nepal. Eleven studies reported DR risk factors association. The duration of diabetes and level of glycemic control were universally acknowledged DR risk factors. We identified 7 studies in the Asia region that researched the level of awareness about diabetes eye complications and the practice of accessing an eye examination. Excepting 1 study in China, others reported a significant proportion being aware that diabetes leads to eye complications. But the awareness was not translated into a positive practice-most studies reported only 20–50% of the persons with diabetes actually having had their eyes examined. The present review highlights the observation that the risk factors for DR need an integrated diabetic care pathway where the eye care team has to work in close collaboration and partnership with a diabetic care team has to reduce the risk of blindness from DR.

Keywords: Awareness, diabetes, diabetic retinopathy, risk factors, utilization


How to cite this article:
Murthy G, Das T. Diabetic care initiatives to prevent blindness from diabetic retinopathy in India. Indian J Ophthalmol 2016;64:50-4

How to cite this URL:
Murthy G, Das T. Diabetic care initiatives to prevent blindness from diabetic retinopathy in India. Indian J Ophthalmol [serial online] 2016 [cited 2020 May 30];64:50-4. Available from: http://www.ijo.in/text.asp?2016/64/1/50/178152


  Magnitude of Diabetes Top


The International Diabetes Federation (IDF) estimated that globally there were 382 million people living with diabetes in 2013 which is likely to increase by 155% to 592 million by 2035.[1] These figures highlight that by 2035, one out of every 10 individuals living in the world would be a person with diabetes. The IDF estimates also show that contrary to popular belief, 80% of the people with diabetes live in low- and middle-income countries (LMICs). The IDF report also shows that the “hot-spots” of diabetes are countries in the Middle-East, Western Pacific, sub-Saharan Africa, and South East Asia where economic development has impacted lifestyles.[1] The 66th World Health Assembly in 2013 adopted a unanimous resolution of a voluntary global action plan for the prevention and control of noncommunicable diseases.[1]

Diabetes contributed to 5.1 million deaths in 2013 which means that 8.4% of global all-cause mortality among adults aged 20–79 years was attributed to diabetes as the underlying cause.[2] Compounding the global challenge further is the fact that 45.8% (175 million) of all persons with diabetes are estimated to be undiagnosed and therefore not aware of their health condition.[3] Four out of every five (83.8%) of the undetected persons with diabetes are in the LMICs.[3]

Over the past two decades, the South Asia region has seen a sharp increase in the magnitude of diabetes and this region is currently home to 72 million adults with diabetes which is projected to increase to 123 million by 2035.[4] The Indian Council for Medical Research supported a study across multiple locations in India (ICMR-INDIAB) which showed a wide variation in the prevalence of diabetes across the country.[5] The weighted prevalence of diabetes (both known and newly detected) was 10.4% in Tamil Nadu, 8.4% in Maharashtra, 5.3% in Jharkhand, and 13.6% in Chandigarh.[5] This study concluded that the projected magnitude for the country would be 62.4 million persons with diabetes and 77.2 million with prediabetes in 2010.[5] The ICMR figures are consistent with IDF estimates for 2013. The IDF estimated that there were 65 million persons with diabetes in India in 2013 and that the number would increase to 109 million by 2035.[6]


  Magnitude of Diabetic Retinopathy Top


Diabetic retinopathy (DR) is a potentially blinding complication of diabetes.[7] It has been documented that the risk of retinal complications increases with increasing duration of diabetes. Available evidence shows that up to 50% of persons with Type 1 diabetes and 30% with Type 2 diabetes develop potentially vision threatening retinal changes over a period of time during a phase when persons with diabetes are not even aware of the early retinal changes.[8] The proportion of global blindness due to DR has increased from 2.1% in 1990 to 2.6% in 2010.[9] This is a 123% increase in just two decades.

Recently, a pooled analysis of 35 population-based studies including data for 22,896 individuals was undertaken.[10] The pooled analysis estimated that the overall prevalence of any DR was 34.6% (95% confidence interval [CI]: 34.5–34.8), while the prevalence for proliferative DR was 6.96% (95% CI: 6.87–7.04) and for diabetic macular edema was 6.81% (95% CI: 6.74–6.89). The overall prevalence of vision-threatening DR (VTDR) was computed to be 10.2% (95% CI: 10.1–10.3).[10] This translates to 93 million persons with DR and 28 million with VTDR in a global context.[10]

This paper reports the prevalence of DR among persons with diabetes from population-based studies in Asia and Africa and looks at the reported risk factors for DR. This will help in identifying specific care pathways for persons with diabetes to prevent blindness due to diabetes.


  Methods Top


We reviewed published data from 2008 onward from PubMed, which ascertained DR in population-based representative samples. This was because an extensive review had reported on available scientifically sound articles prior to 2008.[10] Only English language articles were reviewed by retrieving published manuscripts. Reference lists in the published articles were also searched to identify additional relevant published articles that pertained to prevalence estimates of DR among persons with diabetes. Papers were only reviewed if they reported original research findings related to prevalence at the population level. We reviewed articles, which highlighted Type 2 diabetes mellitus.

With regard to risk factors for DR, in addition to the above criteria, we also included any articles reporting original research findings from India from 2000 onward due to the paucity of research findings available from India, provided they were population-based samples of persons with diabetes and were not included in the pooled data at a global level.[10]

We also looked at original research articles published after 2000 that reported on the awareness of eye complications of diabetes among persons with diabetes. Here we considered both population-based and hospital-based studies only from Asia. We specifically considered awareness among persons with diabetes as our intention was to look at important parameters that affect the diabetes care pathway targeting the reduction of DR-related blindness and visual impairment.


  Results Top


Thirteen research studies reported on the prevalence of DR among persons with diabetes post 2008 [Table 1]. All the studies reported findings on adults, but the age cut-off varied significantly between the studies.[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23] Studies reporting findings on the 50+ aged population reported the much higher prevalence of DR among persons with diabetes compared to studies where the age cut-off for inclusion in the study was much lower [Table 1].[15],[17],[19] The only exception was a study from Sri Lanka, which reported a higher prevalence rate even with a younger cut-off for the age of the population surveyed.[22] We also observed that the reported prevalence of DR among persons with diabetes in China, India, and Nepal was significantly lower than what has been reported at a global level.[11],[12],[13],[16],[21],[23]
Table 1: Comparison of DR prevalence among persons with diabetes in population--based studies[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23]

Click here to view


Eleven studies reported on associations of risk factors for the development of DR [Table 2].[11],[12],[14],[16],[17],[18],[20],[21],[22],[23],[24] The risk factors included in these studies were duration of diabetes, level of glycemic control, hypertension, lipid profile, body mass index (BMI), age, gender, and socioeconomic status/literacy (a proxy indicator for socioeconomic status). Nine (81.8%) studies reported on the duration of diabetes as a risk factor for DR; 2 studies did not comment on the duration of diabetes. Therefore all the studies, which included the duration of diabetes, found that it was a significant risk factor.[11],[16],[17],[18],[20],[21],[22],[23],[24]
Table 2: Risk factors for DR

Click here to view


Ten studies included increasing age as a risk factor and only 2 (20%) found a significant association with DR.[12],[23] Eight studies considered level of glycemic control as a risk factor and 6 (75%) of them found a significant association with DR.[11],[12],[16],[18],[20],[23] Ten studies looked at hypertension as a risk factor, and only 3 (30%) found hypertension to a significant association with DR.[16],[20],[23] Very few studies found an association of literacy/socioeconomic status, BMI, lipid profile, or gender with DR. The review showed that duration of diabetes and level of glycemic control were universally acknowledged as a risk factor for DR.

The level of awareness about the eye complications of diabetes and the practice of accessing an eye examination among persons with diabetes was also reviewed [Table 3]. We could find only 7 studies in the Asia region which researched this perspective.[25],[26],[27],[28],[29],[30],[31] Excepting one study in China,[25] all the others reported a significant proportion being aware that diabetes leads to eye complications. However, this awareness was not translated into a positive practice as most studies reported 20–50% of the persons with diabetes as actually having had their eyes examined.
Table 3: Awareness and practice patterns reported by persons with diabetes

Click here to view



  Discussion Top


It is estimated that the global magnitude of DR will increase from 126.6 million in 2010 to 191 million by 2030.[32] Most of this increase will be fueled by significant increases in Asia and sub-Saharan Africa with large population countries like India and China leading the increase.[6] The present review shows that the prevalence of DR in countries like India and China currently is significantly lower than what has been reported in a pooled global analysis from 35 studies.[10] However, since diabetes occurs at a younger age in Indians than Caucasians,[33] the improving life expectancy in India means that individuals will now live longer with diabetes than ever before.[34] Since the duration of diabetes is a major risk factor for DR, rates of DR are likely to increase over the next few decades. Planning for effective interventions needs to start much before the “epidemic” is on us and therefore strategizing the programs for prevention of blindness due to DR has to start in right earnest at the earliest.

All the available evidence shows that the modifiable risk factors for DR need a comprehensive care approach as mitigating the risk would entail the treating physician/diabetologist takes a pivotal role in the diabetic care pathway. All the studies which were reviewed universally acknowledge that the risk of DR increases with the duration of diabetes.[11],[16],[17],[18],[19],[20],[21],[22],[23] However, this is not a modifiable risk factor and coupled with the observation that nearly 50% of the diabetics are not aware of their diabetic status,[3] programmatic inputs except increasing the awareness among persons with diabetes will not dent the deluge of numbers at risk of DR. What is much more critical in reducing the risk of progression to blindness in DR is the level of glycemic control as glycemic control has been clearly highlighted as a major modifiable risk factor for DR.[11],[12],[16],[18],[20],[23] This needs to be highlighted as the most important intervention as there is adequate evidence that intensive glycemic control can reduce the incidence and progression of DR.[35],[36] Glycemic control is an excellent indicator of the awareness and behavior of persons with long-standing diabetes. Evidence from the review shows that the awareness about the eye complications in diabetes was known to a significant proportion of persons with diabetes.[25],[28],[29] However, this awareness is not translated into accessing eye care services in a significant proportion of persons with diabetes.[25],[26],[27],[28] A study from Singapore demonstrated that a major proportion of persons with diabetes were unaware of eye complications and that poor level of awareness was significantly higher among those who had poor glycemic control and other risk factors for DR.[37] They were also more likely to be able to afford devices such as a glucometer, which would enable them to monitor their blood glucose frequently.

A recent multicenter study in India observed that 45% of the respondents reported that they had a visual loss when they first presented to an eye facility and before their DR was detected.[30] This is consistent with findings reported from many parts of the world that between 25% and 50% of persons with diabetes present with visual loss at the first visit to an eye facility.[28],[38],[39]

The present review highlights the observation that the risk factors for DR need effective management outside the eye care sector as an ophthalmologist is geared toward managing the eye consequences of DR medically or surgically but does not have the wherewithal of achieving good glycemic control, manage hypertension, or lipid levels and monitor dietary modification. Thus, there is an urgent need for a paradigm shift wherein screening for DR should be undertaken at a diabetic service rather than wait for a person with diabetes to come to an eye care facility if vision loss is to be prevented effectively. This needs an integrated approach where the eye care and diabetic care services work together toward the goal of improved quality of life of all persons with diabetes. A recent report also emphasized that both the providers and persons with diabetes strongly advocated for a one-stop integrated approach where the clients could access all diabetic care facilities under one roof.[30] The Queen Elizabeth Diamond Jubilee Trust has recently provided a grant to operationalize an integrated care pathway for diabetic care at the district level by strengthening the public-funded district health system supported by leading eye care and diabetic care nongovernmental organizations to develop sustainable models of integrated care in 10 pilot districts across the country. This may help in setting up scalable models of integrated diabetic care across the country and also be the template for service delivery in many other countries across the commonwealth.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Hirst M. Diabetes in 2013. The new figures. Diabetes Res Clin Pract 2013;102:265.  Back to cited text no. 1
    
2.
IDF Diabetes Atlas Group. Update of mortality attributable to diabetes for the IDF Diabetes Atlas: Estimates for the year 2013. Diabetes Res Clin Pract 2015;109:461-5.  Back to cited text no. 2
    
3.
Beagley J, Guariguata L, Weil C, Motala AA. Global estimates of undiagnosed diabetes in adults. Diabetes Res Clin Pract 2014;103:150-60.  Back to cited text no. 3
    
4.
Ramachandran A, Snehalatha C, Ma RC. Diabetes in South-East Asia: An update. Diabetes Res Clin Pract 2014;103:231-7.  Back to cited text no. 4
    
5.
Anjana RM, Pradeepa R, Deepa M, Datta M, Sudha V, Unnikrishnan R, et al. Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and rural India: Phase I results of the Indian council of medical research-India diabetes (ICMR-INDIAB) study. Diabetologia 2011;54:3022-7.  Back to cited text no. 5
    
6.
Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract 2014;103:137-49.  Back to cited text no. 6
    
7.
Nentwich MM, Ulbig MW. Diabetic retinopathy – Ocular complications of diabetes mellitus. World J Diabetes 2015;6:489-99.  Back to cited text no. 7
    
8.
Stefánsson E, Bek T, Porta M, Larsen N, Kristinsson JK, Agardh E. Screening and prevention of diabetic blindness. Acta Ophthalmol Scand 2000;78:374-85.  Back to cited text no. 8
    
9.
Bourne RR, Stevens GA, White RA, Smith JL, Flaxman SR, Price H, et al. Causes of vision loss worldwide, 1990-2010: A systematic analysis. Lancet Glob Health 2013;1:e339-49.  Back to cited text no. 9
    
10.
Yau JW, Rogers SL, Kawasaki R, Lamoureux EL, Kowalski JW, Bek T, et al. Global prevalence and major risk factors of diabetic retinopathy. Diabetes Care 2012;35:556-64.  Back to cited text no. 10
    
11.
Hu Y, Teng W, Liu L, Chen K, Liu L, Hua R, et al. Prevalence and risk factors of diabetes and diabetic retinopathy in Liaoning province, China: A population-based cross-sectional study. PLoS One 2015;10:e0121477.  Back to cited text no. 11
    
12.
Jonas JB, Nangia V, Khare A, Matin A, Bhojwani K, Kulkarni M, et al. Prevalence and associated factors of diabetic retinopathy in rural central India. Diabetes Care 2013;36:e69.  Back to cited text no. 12
    
13.
Thapa SS, Thapa R, Paudyal I, Khanal S, Aujla J, Paudyal G, et al. Prevalence and pattern of vitreo-retinal diseases in Nepal: The Bhaktapur glaucoma study. BMC Ophthalmol 2013;13:9.  Back to cited text no. 13
    
14.
Schellini SA, Carvalho GM, Rendeiro FS, Padovani CR, Hirai FE. Prevalence of diabetes and diabetic retinopathy in a Brazilian population. Ophthalmic Epidemiol 2014;21:33-8.  Back to cited text no. 14
    
15.
Hajar S, Al Hazmi A, Wasli M, Mousa A, Rabiu M. Prevalence and causes of blindness and diabetic retinopathy in Southern Saudi Arabia. Saudi Med J 2015;36:449-55.  Back to cited text no. 15
    
16.
Raman R, Ganesan S, Pal SS, Kulothungan V, Sharma T. Prevalence and risk factors for diabetic retinopathy in rural India. Sankara Nethralaya diabetic retinopathy epidemiology and molecular genetic study III (SN-DREAMS III), report no 2. BMJ Open Diabetes Res Care 2014;2:e000005.  Back to cited text no. 16
    
17.
Minderhoud J, Pawiroredjo JC, Bueno de Mesquita-Voigt AT, Themen HC, Siban MR, Forster-Pawiroredjo CM, et al. Diabetes and diabetic retinopathy in people aged 50 years and older in the Republic of Suriname. Br J Ophthalmol 2015. pii: Bjophthalmol-2015-307177.  Back to cited text no. 17
    
18.
Yang JY, Kim NK, Lee YJ, Noh JH, Kim DJ, Ko KS, et al. Prevalence and factors associated with diabetic retinopathy in a Korean adult population: The 2008-2009 Korea national health and nutrition examination survey. Diabetes Res Clin Pract 2013;102:218-24.  Back to cited text no. 18
    
19.
Zatic T, Bendelic E, Paduca A, Rabiu M, Corduneanu A, Garaba A, et al. Rapid assessment of avoidable blindness and diabetic retinopathy in Republic of Moldova. Br J Ophthalmol 2015;99:832-6.  Back to cited text no. 19
    
20.
Kyari F, Tafida A, Sivasubramaniam S, Murthy GV, Peto T, Gilbert CE; Nigeria National Blindness and Visual Impairment Study Group. Prevalence and risk factors for diabetes and diabetic retinopathy: Results from the Nigeria national blindness and visual impairment survey. BMC Public Health 2014;14:1299.  Back to cited text no. 20
    
21.
Raman R, Rani PK, Reddi Rachepalle S, Gnanamoorthy P, Uthra S, Kumaramanickavel G, et al. Prevalence of diabetic retinopathy in India: Sankara Nethralaya diabetic retinopathy epidemiology and molecular genetics study report 2. Ophthalmology 2009;116:311-8.  Back to cited text no. 21
    
22.
Katulanda P, Ranasinghe P, Jayawardena R. Prevalence of retinopathy among adults with self-reported diabetes mellitus: The Sri Lanka diabetes and cardiovascular study. BMC Ophthalmol 2014;14:100.  Back to cited text no. 22
    
23.
Namperumalsamy P, Kim R, Vignesh TP, Nithya N, Royes J, Gijo T, et al. Prevalence and risk factors for diabetic retinopathy: A population-based assessment from Theni district, South India. Br J Ophthalmol 2009;93:429-34.  Back to cited text no. 23
    
24.
Narendran V, John RK, Raghuram A, Ravindran RD, Nirmalan PK, Thulasiraj RD. Diabetic retinopathy among self-reported diabetics in Southern India: A population-based assessment. Br J Ophthalmol 2002;86:1014-8.  Back to cited text no. 24
    
25.
Liu L, Chen L. Awareness of diabetic retinopathy is the key step for early prevention, diagnosis and treatment of this disease in China. Patient Educ Couns 2014;94:284-5.  Back to cited text no. 25
    
26.
Addoor KR, Bhandary SV, Khanna R, Rao LG, Lingam KD, Binu VS, et al. Assessment of awareness of diabetic retinopathy among the diabetics attending the peripheral diabetic clinics in Melaka, Malaysia. Med J Malaysia 2011;66:48-52.  Back to cited text no. 26
    
27.
Muecke JS, Newland HS, Ryan P, Ramsay E, Aung M, Myint S, et al. Awareness of diabetic eye disease among general practitioners and diabetic patients in Yangon, Myanmar. Clin Experiment Ophthalmol 2008;36:265-73.  Back to cited text no. 27
    
28.
Thapa R, Poudyal G, Maharjan N, Bernstein PS. Demographics and awareness of diabetic retinopathy among diabetic patients attending the vitreo-retinal service at a tertiary eye care center in Nepal. Nepal J Ophthalmol 2012;4:10-6.  Back to cited text no. 28
    
29.
Cetin EN, Zencir M, Fenkçi S, Akin F, Yildirim C. Assessment of awareness of diabetic retinopathy and utilization of eye care services among Turkish diabetic patients. Prim Care Diabetes 2013;7:297-302.  Back to cited text no. 29
    
30.
South Asia Centre for Disability Inclusive Development Research, Public Health Foundation of India. The Emerging Epidemic of Diabetic Retinopathy in India: Report of a Situational Analysis and Evaluation of Existing Programmes for Screening and Treatment of Diabetic Retinopathy; 2014. p. 1-85. Available from: http://www.iapb.org/sites/iapb.org/files/Queen%20Elizabeth%20Diamond%20Jubilee%20Trust%20-%20situational%20analysis%20of%20DR%20in%20India%20-%20April%202015.pdf. [Last accessed on 2015 Oct 10].  Back to cited text no. 30
    
31.
Saikumar SJ, Giridhar A, Mahesh G, Elias A, Bhat S. Awareness about eye diseases among diabetics – A survey in South India. Community Eye Health 2005;18:97.  Back to cited text no. 31
    
32.
Zheng Y, He M, Congdon N. The worldwide epidemic of diabetic retinopathy. Indian J Ophthalmol 2012;60:428-31.  Back to cited text no. 32
[PUBMED]  Medknow Journal  
33.
Ramachandran A, Snehalatha C. Current scenario of diabetes in India. J Diabetes 2009;1:18-28.  Back to cited text no. 33
    
34.
Panigrahi DN. Life expectancy in India: Contributing factors. Int J Innov Res Dev 2014;3:249-53.  Back to cited text no. 34
    
35.
Aiello LP; DCCT/EDIC Research Group. Diabetic retinopathy and other ocular findings in the diabetes control and complications trial/epidemiology of diabetes interventions and complications study. Diabetes Care 2014;37:17-23.  Back to cited text no. 35
    
36.
Harris Nwanyanwu K, Talwar N, Gardner TW, Wrobel JS, Herman WH, Stein JD. Predicting development of proliferative diabetic retinopathy. Diabetes Care 2013;36:1562-8.  Back to cited text no. 36
    
37.
Huang OS, Tay WT, Tai ES, Wang JJ, Saw SM, Jeganathan VS, et al. Lack of awareness amongst community patients with diabetes and diabetic retinopathy: The Singapore Malay eye study. Ann Acad Med Singapore 2009;38:1048-55.  Back to cited text no. 37
    
38.
Damato EM, Murray N, Szetu J, Sikivou BT, Emma S, McGhee CN. Sight-threatening diabetic retinopathy at presentation to screening services in Fiji. Ophthalmic Epidemiol 2014;21:318-26.  Back to cited text no. 38
    
39.
Tajunisah I, Wong P, Tan L, Rokiah P, Reddy S. Awareness of eye complications and prevalence of retinopathy in the first visit to eye clinic among type 2 diabetic patients. Int J Ophthalmol 2011;4:519-24.  Back to cited text no. 39
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Magnitude of Dia...
Magnitude of Dia...
Methods
Results
Discussion
References
Article Tables

 Article Access Statistics
    Viewed1505    
    Printed9    
    Emailed0    
    PDF Downloaded355    
    Comments [Add]    

Recommend this journal