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GUEST EDITORIAL
Year : 2009  |  Volume : 55  |  Issue : 2  |  Page : 89-90

Risk factors for diabetic retinopathy in rural India


Dr. Mohan's Diabetes Specialitites Centre and Madras Diabetes Research Foundation, Chennai, Tamilnadu, India

Date of Web Publication23-Jun-2009

Correspondence Address:
V Mohan
Dr. Mohan's Diabetes Specialitites Centre and Madras Diabetes Research Foundation, Chennai, Tamilnadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.52837

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How to cite this article:
Mohan V, Pradeepa R. Risk factors for diabetic retinopathy in rural India. J Postgrad Med 2009;55:89-90

How to cite this URL:
Mohan V, Pradeepa R. Risk factors for diabetic retinopathy in rural India. J Postgrad Med [serial online] 2009 [cited 2019 Sep 22];55:89-90. Available from: http://www.jpgmonline.com/text.asp?2009/55/2/89/52837


Diabetes mellitus is a growing health problem in developing countries. According to the Diabetes  Atlas More Details, India with 40.9 million people with diabetes has already become the 'Diabetes Capital of the World' and this number is set to increase to 69.9 million by 2025. [1] The prevalence of diabetes is growing rapidly in both urban and rural areas in India. In 1972, the prevalence of diabetes in urban areas was 2.1% [2] and this has rapidly climbed to 12-16% representing a 600-800% increase in prevalence rates over a 30 year period. [3],[4] Till recently, the prevalence of diabetes was reported to be low in rural areas, but recent studies suggest that the prevalence rate is rapidly increasing even in rural areas, [5],[6] similar to the situation seen in developed countries of the world.

The explosion of diabetes in urban and rural India increases the propensity for developing complications of diabetes i.e. both small vessel (microvascular) and large vessel (macrovascular) disease. [7] The complications of diabetes present a serious challenge to the health care system because people with diabetes have an increased mortality and morbidity compared with those without diabetes. [8] Microvascular complications are more specific to diabetes and indeed, diabetic retinopathy (DR) is considered as the hallmark of diabetes. Recent epidemiological studies have provided valuable information on the prevalence of DR in the urban south Indian population. [9],[10],[11] However, there is very few data on the prevalence of DR in rural population, where 72% of India's population lives. Although prevalence rates of diabetes are lower in rural areas, the absolute number of people with diabetes is actually higher (23.0 million) compared to urban areas (17.9 million). Screening for diabetes and its complications is hardly ever done in rural areas. This results in a large burden of undiagnosed diabetes and its associated complications due to delayed diagnosis and/or improper treatment. [12]

In the light of these facts, the cross-sectional study by Rani et al. , in this issue [13] is of interest. The authors studied a total of 26,519 rural self-reported subjects with diabetes (age ≥30 years) who attended 198 DR screening camps conducted in three southern districts of Tamilnadu. The study reports on the prevalence and risk factors for the presence and severity of DR. The authors report that the prevalence of DR among the self-reported diabetic subjects, diagnosed using binocular indirect ophthalmoscope is 17.6% while that of sight threatening retinopathy was 5.3%. In the Aravind Comprehensive Eye Study conducted in a rural population in three districts of Tamilnadu [Madurai, Tirunelveli, and V.O. Chidambaranar], the prevalence of DR was 10.5% in type 2 diabetic subjects. [14] Rani et al. , [15] have earlier reported age and sex adjusted prevalence of DR to be 18% in rural areas (Kancheepuram and Vellore) and 17% in the urban area (Chennai) in Tamil Nadu. It is of interest that the prevalence rate of DR reported in this rural study (17.6%) is similar to that reported among urban south Indian population based on retinal photography. [9] The two earlier population based studies done in the neighboring states of Andhra Pradesh and Kerala in South India among urban self reported diabetic subjects have reported a 22.4% and 26.8% prevalence of DR, respectively. One would expect the prevalence of DR to be higher in a rural population. It is possible that if retinal photography were used, the prevalence of DR would have been higher in this study.

The prevalence of DR in persons with known diabetes was 17.8%, while in persons with newly detected diabetes (duration of diabetes <1 month) it was 10.2%. Persons with known diabetes had significantly higher prevalence of referable DR compared to newly detected diabetes [30.2% vs. 25.4%]. There is evidence that DR may be present even at the time of diagnosis of type 2 diabetes due to the insidious onset of this disease with estimates that on an average, the disease may set in up to 7 years before the initial diagnosis of diabetes. [16] The prevalence of DR among newly diagnosed diabetic subjects in this study was 10.2%, which is higher than the figure of 7.3%, reported earlier in a clinic-based population [17] as well as in an earlier population based study from the same region (5.1%). [9]

Rani et al ., [13] reported that duration of diabetes, lower BMI, systolic blood pressure, insulin intake, and male gender are risk factors associated with any DR. The risk factors associated with severity of DR were longer duration of diabetes, elevated systolic blood pressure, lower BMI, and those on insulin therapy. In another study of urban South Indian type 2 diabetic subjects, duration of diabetes, HbA1c, male gender, macroalbuminuria, and insulin therapy were identified as independent risk factors for the severity of DR. [18] The risk factors identified in this study have been implicated as risk factors in the development of DR in many studies: duration of diabetes, [18],[19] hypertension, [20] male preponderance, [10],[18] and insulin intake. [18],[21] However, the association of BMI and DR has not been consistently demonstrated in all studies. The current data shows that DR is related to lower BMI, as observed in the Cree population of James Bay [22] and multiethnic population of Mauritius [23] as well as the study by Rema et al ., [9] in south India. However, in some studies conducted in developed countries, higher BMI is associated with DR subjects with type 2 diabetes. [21],[24]

With the prevalence of diabetes reaching epidemic proportions in India, DR is fast becoming significant cause of visual impairment. Scarcity of data on prevalence of DR is regarded as one of the barriers to instituting and strengthening cost-effective prevention and control of visual impairment due to diabetes. In addition, identifying the risk factors for DR is imperative, given the association between the risk factors and increased morbidity. Regular screening for DR and more aggressive management of modifiable risk factors could reduce the numbers of people who develop sight-threatening retinopathy. Rural areas in developing countries like India have additional challenges such as the lack of awareness due to illiteracy and limited access to specialized health care facilities, which even if available, would be largely unaffordable due to the prevailing poverty. Therefore there is an urgent need to make diabetes care "Available, Accessible, and Affordable" to the rural population. Routine retinal screening in diabetic individuals is thus mandatory to detect DR in its early stages and thus reduce the burden due to DR in developing countries like India.

 
 :: References Top

1.Sicree R, Shaw J, Zimmet P. Diabetes and impaired glucose tolerance. In: Gan D, editor. Diabetes Atlas. International Diabetes Federation. 3rd ed. Belgium: International Diabetes Federation; 2006. p. 15-103.  Back to cited text no. 1    
2.Ahuja MM. Epidemiology studies on diabetes mellitus in India. In. Ahuja MM, editor. Epidimiology of diabetes in developing countries, Interprint. New Delhi: 1979. p. 29-38.  Back to cited text no. 2    
3.Ramachandran A, Snehalatha C, Kapur A, Vijay V, Mohan V, Das AK, et al. Diabetes Epidemiology Study Group In India (DESI): High prevalence of diabetes and impaired glucose tolerance in India: National Urban Diabetes Survey. Diabetologia 2001;44:1094-101.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Mohan V, Deepa M, Deepa R, Shanthirani CS, Farooq S, Ganesan A, et al . Secular trends in the prevalence of diabetes and impaired glucose tolerance in urban South India-the Chennai Urban Rural Epidemiology Study (CURES-17). Diabetologia 2006;49:1175-8.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Mohan V, Mathur P, Deepa R, Deepa M, Shukla DK, Menon GR, et al. Urban rural differences in prevalence of self-reported diabetes in India: The WHO-ICMR Indian NCD risk factor surveillance. Diab Res Clin Pract 2008;80:159-68.  Back to cited text no. 5    
6.Chow CK, Raju PK, Raju R, Reddy KS, Cardona M, Celermajer DS, et al . The prevalence and management of diabetes in rural India. Diabetes Care 2006;29:1717-8.  Back to cited text no. 6    
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8.Mohan V, Shanthirani CS, Deepa M, Deepa R, Unnikrishnan RI, Datta M. Mortality rates due to diabetes in a selected urban South Indian population: The Chennai Urban Population Study (CUPS). J Assoc Physicians India 2006;54:113-7.   Back to cited text no. 8  [PUBMED]  
9.Rema M, Premkumar S, Anitha B, Deepa R, Pradeepa R, Mohan V. Prevalence of diabetic retinopathy in Urban India: The Chennai Urban Rural Epidemiology Study (CURES) Eye Study - 1. Invest Ophthal Vis Sci 2005;46:2328-33.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.Dandona L, Dandona R, Naduvilath TJ, McCarty CA, Rao GN. Population based assessment of diabetic retinopathy in an urban population in southern India. Br J Ophthal 1999;83:937-40.  Back to cited text no. 10    
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12.Suresh S, Deepa R, Pradeepa R, Rema M, Mohan V. Large scale diabetes awareness and prevention in South India. Diabetes Voice 2005;50:11-4.  Back to cited text no. 12    
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14.Nirmalan PK, Katz J, Robin AL, Tielsch JM, Namperumalsamy P, Kim R, et al . Prevalence of vitreoretinal disorders in a rural population of southern India: The Aravind Comprehensive Eye Study. Arch Ophthalmol 2004;122:581-6.  Back to cited text no. 14  [PUBMED]  
15.Rani PK, Raman R, Sharma V, Mahuli SV, Tarigopala A, Sudhir RR, et al. Analysis of a comprehensive diabetic retinopathy screening model for rural and urban diabetics in developing countries.Br J Ophthalmol 2007;91:1425-9.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]
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18.Pradeepa R, Anitha B, Mohan V, Ganesan A, Rema M. Risk factors for diabetic retinopathy in a South Indian Type 2 diabetic population: The Chennai Urban Rural Epidemiology Study (CURES) Eye Study 4. Diabet Med 2008;25:536-42.   Back to cited text no. 18  [PUBMED]  [FULLTEXT]
19.Tapp RJ, Shaw JE, Harper CA, de Courten MP, Balkau B, McCarty DJ, et al . The prevalence of and factors associated with diabetic retinopathy in the Australian population. Diabetes Care 2003;26:1731-7.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]
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21.UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 1998;352:854-65.  Back to cited text no. 21    
22.Maberley A, King W, Cruess AF, Koushik A. Risk factors for diabetic retinopathy in the Cree of James Bay. Ophthalmic Epidemiol 2002;9:153-67.   Back to cited text no. 22    
23.Dowse GK, Humphrey AR, Collins VR, Plehwe W, Gareeboo H, Fareed D, et al . Prevalence and risk factors for diabetic retinopathy in the multiethnic population of Mauritius. Am J Epidemiol 1998;147:448-57.  Back to cited text no. 23  [PUBMED]  [FULLTEXT]
24.van Leiden HA, Dekker JM, Moll AC, Nijpels G, Heine RJ, Bouter LM, et al . Blood pressure, lipids, and obesity are associated with retinopathy: The Hoorn study. Diabetes Care 2002;25:1320-5.  Back to cited text no. 24  [PUBMED]  [FULLTEXT]



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2004 - Journal of Postgraduate Medicine
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