The association of smoking and risk of diabetic retinopathy in patients with type 1 and type 2 diabetes: a meta-analysis

Influence of quitting smoking on diabetes-related complications: A scoping review with a systematic search strategy

INTRODUCTION

Smoking in people with diabetes markedly elevates their risk of developing complications and increases the likelihood of cardiovascular mortality. This review is the first to specifically provide evidence-based analysis about the influence of quitting smoking on diabetes-related complications in people with type 2 diabetes.

METHOD

The present review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews. All human clinical studies assessing the effects of stopping smoking cessation on diabetes-related complications were included. PubMed and Embase were screened until January 2024. References of primary studies and principal peer-reviewed scientific journals in the field were manually screened.

RESULTS

We identified a total of 1023 studies. Only 26 met the criteria for eligibility. In general quitting smoking is associated with decreased risks of myocardial infarction and ischemic stroke. Regarding microvascular complications, the strongest evidence for the beneficial effects of smoking cessation is observed in diabetic nephropathy. However, the relationship between smoking cessation and retinopathy, neuropathy, diabetic foot complications and diabetic-related erectile dysfunction, is poorly investigated.

CONCLUSION

Quitting smoking offers significant advantages in managing diabetes-related complications, significantly lowering the risks of myocardial infarction, ischemic stroke, and diabetic nephropathy. This underscores the importance of cessation. Providing evidence-based information on the benefits of stopping smoking for people with type 2 diabetes who smoke, can bolster smoking cessation efforts in the context of diabetes management.

Prediction of Diabetes and Prediabetes among the Saudi Population Using a Non-Invasive Tool (AUSDRISK)

Background and Objectives: Screening for type 2 diabetes mellitus (DM2) aims to identify asymptomatic individuals who may be at a higher risk, allowing proactive interventions. The objective of this study was to predict the incidence of DM2 and prediabetes in the Saudi population over the next five years. Materials and Methods: The study was conducted in the Aseer region through August 2023 using a cross-sectional survey for data collection. A multistage stratified random sampling technique was adopted, and data were collected through face-to-face interviews using the validated Arabic version of the Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK). Results: In total, 652 individuals were included in the study. Their mean age was 32.0 ± 12.0 years; 53.8% were male, 89.6% were from urban areas, and 55.8% were single. There were statistically significant differences between males and females in AUSDRISK items, including age, history of high blood glucose, use of medications for high blood pressure, smoking, physical activity, and measurements of waist circumference (p < 0.05). Based on AUSDRISK scores, 46.2% of the included participants were predicted to develop impaired glucose tolerance within the coming five years (65.8% among females vs. 23.6%), and 21.9% were predicted to develop DM2 (35.6% among males vs. 6.0% among females); this difference was statistically significant (p = 0.0001). Conclusions: Urgent public health action is required to prevent the increasing epidemic of DM2 in Saudi Arabia.

Alzheimer's disease as a causal risk factor for diabetic retinopathy: a Mendelian randomization study

Objectives

This study aims to investigate the causal relationship between Alzheimer's Disease (AD) and Diabetic Retinopathy (DR).

Methods

Employing Mendelian Randomization (MR), Generalized Summary-data-based Mendelian Randomization (GSMR), and the MR-Steiger test, this study scrutinizes the genetic underpinnings of the hypothesized causal association between AD and DR, as well as its Proliferative DR (PDR) and Non-Proliferative DR (NPDR) subtypes. Comprehensive data from Genome-Wide Association Studies (GWAS) were analyzed, specifically AD data from the Psychiatric Genomics Consortium (71,880 cases/383,378 controls), and DR, PDR, and NPDR data from both the FinnGen consortium (FinnGen release R8, DR: 5,988 cases/314,042 controls; PDR: 8,383 cases/329,756 controls; NPDR: 3,446 cases/314,042 controls) and the IEU OpenGWAS (DR: 14,584 cases/176,010 controls; PDR: 8,681 cases/204,208 controls; NPDR: 2,026 cases/204,208 controls). The study also incorporated Functional Mapping and Annotation (FUMA) for an in-depth analysis of the GWAS results.

Results

The MR analyses revealed that genetic susceptibility to AD significantly increases the risk of DR, as evidenced by GWAS data from the FinnGen consortium (OR: 2.5090; 95% confidence interval (CI):1.2102-5.2018, false discovery rate P-value (PFDR)=0.0201; GSMR: bxy=0.8936, bxy_se=0.3759, P=0.0174), NPDR (OR: 2.7455; 95% CI: 1.3178-5.7197, PFDR=0.0166; GSMR: bxy=0.9682, bxy_se=0.3802, P=0.0126), and PDR (OR: 2.3098; 95% CI: 1.2411-4.2986, PFDR=0.0164; GSMR: bxy=0.7962, bxy_se=0.3205, P=0.0129) using DR GWAS from FinnGen consortium. These results were corroborated by DR GWAS datasets from IEU OpenGWAS. The MR-Steiger test confirmed a significant association of all identified instrumental variables (IVs) with AD. While a potential causal effect of DR and its subtypes on AD was identified, the robustness of these results was constrained by a low power value. FUMA analysis identified OARD1, NFYA, TREM1 as shared risk genes between DR and AD, suggesting a potential genetic overlap between these complex diseases.

Discussion

This study underscores the contribution of AD to an increased risk of DR, as well as NPDR and PDR subtypes, underscoring the necessity of a holistic approach in the management of patients affected by these conditions.

Aldose Reductase as a Key Target in the Prevention and Treatment of Diabetic Retinopathy: A Comprehensive Review

The escalating global prevalence of diabetes mellitus (DM) over the past two decades has led to a persistent high incidence of diabetic retinopathy (DR), necessitating screening for early symptoms and proper treatment. Effective management of DR aims to decrease vision impairment by controlling modifiable risk factors including hypertension, obesity, and dyslipidemia. Moreover, systemic medications and plant-based therapy show promise in advancing DR treatment. One of the key mechanisms related to DR pathogenesis is the polyol pathway, through which aldose reductase (AR) catalyzes the conversion of glucose to sorbitol within various tissues, including the retina, lens, ciliary body and iris. Elevated glucose levels activate AR, leading to osmotic stress, advanced glycation end-product formation, and oxidative damage. This further implies chronic inflammation, vascular permeability, and angiogenesis. Our comprehensive narrative review describes the therapeutic potential of aldose reductase inhibitors in treating DR, where both synthetic and natural inhibitors have been studied in recent decades. Our synthesis aims to guide future research and clinical interventions in DR management.

Parallelism and non-parallelism in diabetic nephropathy and diabetic retinopathy

Diabetic nephropathy (DN) and diabetic retinopathy (DR), as microvascular complications of diabetes mellitus, are currently the leading causes of end-stage renal disease (ESRD) and blindness, respectively, in the adult working population, and they are major public health problems with social and economic burdens. The parallelism between the two in the process of occurrence and development manifests in the high overlap of disease-causing risk factors and pathogenesis, high rates of comorbidity, mutually predictive effects, and partial concordance in the clinical use of medications. However, since the two organs, the eye and the kidney, have their unique internal environment and physiological processes, each with specific influencing molecules, and the target organs have non-parallelism due to different pathological changes and responses to various influencing factors, this article provides an overview of the parallelism and non-parallelism between DN and DR to further recognize the commonalities and differences between the two diseases and provide references for early diagnosis, clinical guidance on the use of medication, and the development of new drugs.

Insights Into Visual Rehabilitation: Pan-Retinal Photocoagulation for Proliferative Diabetic Retinopathy

This review comprehensively explores pan-retinal photocoagulation (PRP) as a pivotal intervention in visually rehabilitating individuals afflicted with proliferative diabetic retinopathy (PDR). The review begins by elucidating the significance of PDR within the spectrum of diabetic retinopathy (DR), emphasizing the progressive nature of the disease and the consequential impact on visual health. A detailed analysis of PRP follows, encompassing its definition, purpose, and historical development, shedding light on the procedural intricacies and mechanisms of action. The postoperative care and follow-up section underscores the necessity of vigilant monitoring for complications, visual recovery, and the importance of regular ophthalmic check-ups. The subsequent discussion delves into patient education and counseling, stressing the need to manage expectations, encourage lifestyle modifications, and highlight the significance of follow-up appointments. The review concludes with insights into future directions, including advancements in laser technology and emerging therapies, offering a glimpse into the evolving landscape of DR management. By addressing ongoing challenges and embracing innovative approaches, this review provides a comprehensive guide for clinicians, researchers, and healthcare practitioners who visually rehabilitate individuals struggling with PDR.

Modifiable lifestyle, mental health status and diabetic retinopathy in U.S. adults aged 18-64 years with diabetes: a population-based cross-sectional study from NHANES 1999-2018

BACKGROUND

The relationship between integrated lifestyles, mental status and their impact on overall well-being has attracted considerable attention. This study aimed to evaluate the association between lifestyle factors, depression and diabetic retinopathy (DR) in adults aged 18-64 years.

METHODS

A cohort of 3482 participants diagnosed with diabetes was drawn from the National Health and Nutrition Examination Survey (NHANES) spanning the years 1999-2018. DR was defined based on self-reported diabetic retinopathy diagnoses by professional physicians, relying on Diabetes Interview Questionnaires. Subgroup analysis was employed to assess lifestyle and psychological factors between participants with DR and those without, both overall and stratified by diabetic duration. Continuous variables were analyzed using the student's t test, while weighted Rao-Scott χ2 test were employed for categorical variables to compare characteristics among the groups.

RESULTS

Of the 3482 participants, 767 were diagnosed with diabetic retinopathy, yielding a weighted DR prevalence of 20.8%. Patients with DR exhibited a higher prevalence of heavy drinking, depression, sleep deprivation, and insufficient physical activity compared to those without DR. Furthermore, multivariable logistic regression analysis revealed that sleeping less than 5 h (OR = 3.18, 95%CI: 2.04-4.95, p < 0.001) and depression (OR = 1.35, 95%CI:1.06-1.64, p = 0.025) were associated with a higher risk of DR, while moderate drinking (OR = 0.49, 95%CI: 0.32-0.75, p = 0.001) and greater physical activity (OR = 0.64, 95%CI: 0.35-0.92, p = 0.044) were identified as protective factors.

CONCLUSIONS

Adults aged 18-64 years with DR exhibited a higher prevalence of lifestyle-related risk factors and poorer mental health. These findings underscore the need for concerted efforts to promote healthy lifestyles and positive emotional well-being in this population.

Ferroptosis in the ageing retina: A malevolent fire of diabetic retinopathy

Ageing retina is prone to ferroptosis due to the iron accumulation and impaired efficiency of intracellular antioxidant defense system. Ferroptosis acts as a cell death modality that is characterized by the iron-dependent accumulation of lipid peroxidation. Ferroptosis is distinctively different from other types of regulated cell death (RCD) at the morphological, biochemical, and genetic levels. Diabetic retinopathy (DR) is a common microvascular complication of diabetes. Its prevalence and severity increase progressively with age. Recent reports have shown that ferroptosis is implicated in the pathophysiology of DR. Under hyperglycemia condition, the endothelial cell and retinal pigment epithelium (RPE) cell will undergo ferroptosis, which contributes to the increased vascular permeability and the disrupted blood retinal barrier (BRB). The underlying etiology of DR can be attributed to the impaired BRB integrity and subsequent damages of the neurovascular units. In the absence of timely intervention, the compromised BRB can ultimately cause profound visual impairments. In particular, the ageing retina is vulnerable to ferroptosis, and hyperglycemia will accelerate the progression of this pathological process. In this article, we discuss the contributory role of ferroptosis in DR pathogenesis, and summarize recent therapeutic trials that targeting the ferroptosis. Further study on the ferroptosis mediated damage would enrich our knowledge of DR pathology, and promote the development of clinical treatment for this degenerative retinopathy.

Diabetic Retinopathy and Brain Structure, Cognition Function, and Dementia: A Bidirectional Mendelian Randomization Study

BACKGROUND

Accumulating evidence has demonstrated that hyperglycemia is a possible risk factor for mild cognitive impairment or Alzheimer's disease. Diabetic retinopathy (DR) has been identified as a risk factor for dementia in patients with diabetes.

OBJECTIVE

This study aimed to investigate the causal relationships between DR and brain structure, cognitive function, and dementia.

METHODS

We performed bidirectional two-sample Mendelian randomization for DR, brain structure, cognitive function, and dementia using the inverse-variance weighted method.

RESULTS

Inverse-variance weighted analysis showed the association of DR with vascular dementia (OR = 1.68, 95% CI: 1.01-2.82), and dementia was significantly associated with the increased risk of non-proliferative DR (NPDR) (OR = 1.76, 95% CI: 1.04-2.98). Furthermore, better cognitive performance was significantly associated with a reduced risk of NPDR (OR = 0.85, 95% CI: 0.74-0.98). No association was observed between DR and brain structure.

CONCLUSIONS

These findings suggest that the association of DR with vascular dementia. The reciprocal effect of cognitive performance and dementia on NPDR risk highlights the potential benefits of dementia prevention for reducing the burden of DR.

Smoking, dietary factors and major age-related eye disorders: an umbrella review of systematic reviews and meta-analyses

BACKGROUND

There is accumulating evidence of the associations between age-related eye diseases (AREDs) and smoking or dietary factors. We aimed to provide an umbrella review of the published literature pertaining to smoking or dietary intake as risk factors for major AREDs including cataract, glaucoma, age-related macular degeneration (AMD) and diabetic retinopathy.

METHODS

We searched for pertinent systematic reviews or meta-analyses in PubMed and Web of Science until 16 April 2022. We reperformed the meta-analysis of each association using random effects models. The heterogeneity and 95% prediction interval were calculated. The presence of small-study effect or excess significance bias was also assessed.

RESULTS

In total, 64 associations from 25 meta-analyses and 41 associations from 10 qualitative systematic reviews were evaluated. There was convincing (class I) evidence for only one association, namely current smoking and cataract. Two factors had highly suggestive (class II) evidence, namely ever smoking associated with cataract and fish consumption associated with AMD. We also found suggestive (class III) evidence for associations between the dietary intake of omega-3 polyunsaturated fatty acid, lutein, zeaxanthin, vitamin C and the risk of cataract.

CONCLUSIONS

Smoking as a risk factor for cataract was the most robust association we identified. We also identified several dietary elements associated with AREDs. Large prospective studies are warranted to further examine the associations discussed in this review.

PROSPERO REGISTRATION NUMBER

CRD42022339082.

Advances and Perspectives in Relation to the Molecular Basis of Diabetic Retinopathy-A Review

Diabetes mellitus (DM) is a growing problem nowadays, and diabetic retinopathy (DR) is its predominant complication. Currently, DR diagnosis primarily relies on fundoscopic examination; however, novel biomarkers may facilitate that process and make it widely available. In this current review, we delve into the intricate roles of various factors and mechanisms in DR development, progression, prediction, and their association with therapeutic approaches linked to the underlying pathogenic pathways. Specifically, we focus on advanced glycation end products, vascular endothelial growth factor (VEGF), asymmetric dimethylarginine, endothelin-1, and the epigenetic regulation mediated by microRNAs (miRNAs) in the context of DR.

Factors associated with glycemic control and diabetes complications in a group of Saudi patients with type 2 diabetes

Poor glycemic control is a risk factor for micro and macrovascular complications of diabetes. The aim of this study was to assess the prevalence and factors related to suboptimal glycemic control and diabetes complications in a group of patients with type 2 diabetes mellitus (T2DM). This cross-sectional descriptive study conducted in Al Qassim region, Saudi Arabia. Two hundred patients with T2DM were enrolled. Demographic, social, and self-care behavior data were collected. A thorough clinical evaluation was done. Glycated hemoglobin, lipid, and kidney profile results were recorded. Mann-Whitney test was used to compare different groups. For comparing categorical data, Chi-square (χ2) test was performed. Multivariate logistic regression analyses used to detect predictors of poor glycemic control and macrovascular and microvascular complications. The median age of patients was 58 years, and 62% of them were males. Only 22.5% of patients had glycated hemoglobin <7%. Forty-four patients (22%) had evidence of macrovascular complications. Retinopathy, neuropathy, and nephropathy were found in 42.5%, 32.5%, and 12%, respectively. Longer diabetes duration was significantly associated with poor glycemic control (OR = 1.006, P < .005). The age of the patients was independently associated with macrovascular complications (OR = 1.050, P = .029). Hyperlipidemia was significantly associated with neuropathy (OR = 0.229, P = .043) and retinopathy (OR = 12.887, P = .003). Although physical activity was lower in patients with suboptimal glycemic levels (P = .024), cardiovascular disease (P = .030), neuropathy (P < .001), retinopathy (P < .001), and nephropathy (P = .019), multivariate analysis showed that it was only independently associated with neuropathy (OR = 0.614, P = .001). The prevalence of suboptimal glycemic control is high in the studied population. Effective health measures are urgently needed to stop diabetes complications, especially retinopathy and neuropathy. Elderly people with long durations of diabetes, and lower physical activity should be the focus of the interventions. Tailored exercise programs are particularly needed for better diabetes control and for the prevention of complications in patients with T2DM.

Discovering potential pathways between type 2 diabetes mellitus and diabetic retinopathy: A big data analysis of the South Korean National Sample Cohort

Diabetes mellitus, a prevalent metabolic disorder, is associated with a multitude of complications that necessitate vigilant management post-diagnosis. A notable complication, diabetic retinopathy, could lead to intense ocular injury, including vision impairment and blindness, due to the impact of the disease. Studying the transition from diabetes to diabetic retinopathy is paramount for grasping and halting the progression of complications. In this study, we examine the statistical correlation between type 2 diabetes mellitus and retinal disorders classified elsewhere, ultimately proposing a comprehensive disease network. The National Sample Cohort of South Korea, containing approximately 1 million samples and primary diagnoses based on the International Statistical Classification of Diseases and Related Health Problems 10th Revision classification, was utilized for this retrospective analysis. The diagnoses of both conditions displayed a statistically significant correlation with a chi-square test value of P < .001, and the t test for the initial diagnosis date also yielded a P < .001 value. The devised network, comprising 27 diseases and 142 connections, was established through statistical evaluations. This network offers insight into potential pathways leading to diabetic retinopathy and intermediary diseases, encouraging medical researchers to further examine various risk factors associated with these connections.

Development and validation of a risk prediction model for diabetic retinopathy in type 2 diabetic patients

To establish a risk prediction model and make individualized assessment for the susceptible diabetic retinopathy (DR) population in type 2 diabetic mellitus (T2DM) patients. According to the retrieval strategy, inclusion and exclusion criteria, the relevant meta-analyses on DR risk factors were searched and evaluated. The pooled odds ratio (OR) or relative risk (RR) of each risk factor was obtained and calculated for β coefficients using logistic regression (LR) model. Besides, an electronic patient-reported outcome questionnaire was developed and 60 cases of DR and non-DR T2DM patients were investigated to validate the developed model. Receiver operating characteristic curve (ROC) was drawn to verify the prediction accuracy of the model. After retrieving, eight meta-analyses with a total of 15,654 cases and 12 risk factors associated with the onset of DR in T2DM, including weight loss surgery, myopia, lipid-lowing drugs, intensive glucose control, course of T2DM, glycated hemoglobin (HbA1c), fasting plasma glucose, hypertension, gender, insulin treatment, residence, and smoking were included for LR modeling. These factors, followed by the respective β coefficient was bariatric surgery (− 0.942), myopia (− 0.357), lipid-lowering drug follow-up < 3y (− 0.994), lipid-lowering drug follow-up > 3y (− 0.223), course of T2DM (0.174), HbA1c (0.372), fasting plasma glucose (0.223), insulin therapy (0.688), rural residence (0.199), smoking (− 0.083), hypertension (0.405), male (0.548), intensive glycemic control (− 0.400) with constant term α (− 0.949) in the constructed model. The area under receiver operating characteristic curve (AUC) of the model in the external validation was 0.912. An application was presented as an example of use. In conclusion, the risk prediction model of DR is developed, which makes individualized assessment for the susceptible DR population feasible and needs to be further verified with large sample size application.

Smoking and environmental tobacco smoke exposure: implications in ocular disorders

PURPOSE

This article aims to gather and review the available knowledge on several implications of smoking and environmental tobacco smoke (ETS) exposure in ocular disorders and provides pathomechanistic insights where applicable.

MATERIALS AND METHODS

PubMed and Scopus databases were searched for relevant studies on the association of smoking and ETS exposure with various ocular disorders. Studies with different evidence levels, e.g., in-vivo, case-control, cohort, and meta-analysis, were included.

RESULTS

Smoking is an established, modifiable risk factor in several ocular diseases, including cataract, age-related macular degeneration, and Graves' ophthalmopathy; smokers are subject to more severe disease courses and less favorable treatment outcomes. Uveitis is twice as likely in smokers; smoking may also delay its resolution. Smoking and ETS exposure are major risk factors for diseases of other organs, with associated ocular complications as well, such as diabetes mellitus. ETS exposure is also associated with ocular surface pathologies, including dry eye syndrome. In children, early-life ETS exposure and maternal smoking during pregnancy are strongly associated with refractive errors and strabismus. Currently, available data on potential risks attributable to ETS exposure regarding ocular diseases are scarce and, in some instances, controversial.

CONCLUSION

In addition to smoking, ETS exposure is also a significant public health concern with possible links to several ocular diseases. However, the level of education of at-risk populations in this regard does not match the strength of the evidence.

Prevalence of diabetes in the USA from the perspective of demographic characteristics, physical indicators and living habits based on NHANES 2009-2018

OBJECTIVE

To determine differences in DM in the U.S. population according to demographic characteristics, physical indicators and living habits.

METHODS

23 546 participants in the 2009 to 2018 National Health and Nutrition Examination Survey (NHANES) who were 20 year of age or older and not pregnant. All analyses used weighted samples and considered the stratification and clustering of the design. Specific indicators include length of leg (cm), BMI (kg/cm²), TCHOL (mg/dL), fasting plasma glucose (mg/dL) and comparison of means and the proportion of participants with DM.

RESULTS

The prevalence of DM in the USA has been rising modestly in the past decade, and were consistent and robust for the observed differences in age, sex, and ethnicity. Compared with white participants, black participants and Mexican-American were both more likely (P<0.001) to have diabetes: 14.6% (CI, 13.6% to 15.6%) among black participants, 10.6% (CI, 9.9% to 11.3%) among white participants, and 13.5% (CI, 11.9% to 15.2%) among Mexican-American participants. The prevalence of diabetes is increasing with age, males peaked around the 60s, and women around the 70s. The overall mean leg length and TCHOL was lower in diabetics than in non-diabetics (1.07 cm, 18.67 mg/dL, respectively), while mean BMI were higher in diabetics than in non-diabetics (4.27 kg/cm2). DM had the greatest effect on decline of TCHOL in white participants (23.6 mg/dL), less of an effect in black participants (9.67 mg/dL), and the least effect in Mexican-American participants (8.25 mg/dL). Notably, smoking had great effect on percent increment of DM in whites (0.2%), and have little effect on black and Mexican-Americans.

CONCLUSIONS

DM is more common in the general population than might be clinically recognized, and the prevalence of DM was associated to varying degrees with many indicators of demographic characteristics, physical indicators, and living habits. These indicators should be linked with medical resource allocation and scientific treatment methods to comprehensively implement the treatment of DM.

Association Between Uric Acid to HDL Cholesterol Ratio and Diabetic Complications in Men and Postmenopausal Women

AIM

Previous studies have implicated the uric acid to high-density lipoprotein cholesterol (HDL-C) ratio (UHR) was associated with type 2 diabetes. However, the association between UHR and diabetes-related vascular damages is still unclear.

METHODS

The total of 4551 patients with type 2 diabetes from the cross-sectional Environmental Pollutant Exposure and Metabolic Diseases in Shanghai study (METAL study) were enrolled. UHR was calculated as uric acid to HDL-C ratio. Cardiovascular disease (CVD) was defined as previously diagnosed with stroke, coronary heart disease, or peripheral arterial disease. Chronic kidney disease (CKD) was defined as estimated glomerular filtration rate ≤60 mL/min/1.73 m² and/or urinary albumin to creatinine ratio ≥30 mg/g. Fundus image was examined by trained individuals and degree of diabetic retinopathy (DR) was evaluated.

RESULTS

UHR was positively correlated with CVD (OR = 1.28, 95% CI: 1.02-1.61) and CKD (OR = 1.78, 95% CI: 1.39-2.27) after adjusting for all confounders. No association was found between UHR and DR. In stratified analyses, UHR was predominantly correlated with CVD in diabetic patients with age older than 65 (OR = 1.41, 95% CI: 1.08-1.85), female (OR = 1.43, 95% CI: 1.06-1.94) and BMI≥24kg/m² (OR = 1.57, 95% CI: 1.17-2.11). A 1-SD increment of UHR was also positively associated with CVD (OR 1.26, 95% CI 1.03, 1.15) and CKD (OR 1.28, 95% CI 1.20,1.39). UHR was positively associated with CKD in all subgroups analysis. No significant interaction effect was observed between UHR and all subgroup variables in CVD and CKD risk.

CONCLUSION

Our study reported a positive association between the UHR and diabetic-related vascular complications in men and postmenopausal women. The relationship between the UHR and DR seems to be uncertain and requires further investigation. And no significant interaction effect was observed between the UHR and all subgroup variables in CVD and CKD risk.

Differences in retinopathy prevalence and associated risk factors across 11 countries in three continents: A cross-sectional study of 156,090 children and adolescents with type 1 diabetes

OBJECTIVE

To examine the prevalence, time trends, and risk factors of diabetic retinopathy (DR) among youth with type 1 diabetes (T1D) from 11 countries (Australia, Austria, Denmark, England, Germany, Italy, Luxemburg, Netherlands, Slovenia, United States, and Wales).

SUBJECTS AND METHODS

Data on individuals aged 10-21 years with T1D for >1 year during the period 2000-2020 were analyzed. We used a cross-sectional design using the most recent year of visit to investigate the time trend. For datasets with longitudinal data, we aggregated the variables per participant and observational year, using data of the most recent year to take the longest observation period into account. DR screening was performed through quality assured national screening programs. Multiple logistic regression models adjusted for the year of the eye examination, age, gender, minority status, and duration of T1D were used to evaluate clinical characteristics and the risk of DR.

RESULTS

Data from 156,090 individuals (47.1% female, median age 15.7 years, median duration of diabetes 5.2 years) were included. Overall, the unadjusted prevalence of any DR was 5.8%, varying from 0.0% (0/276) to 16.2% between countries. The probability of DR increased with longer disease duration (aORper-1-year-increase  = 1.04, 95% CI: 1.03-1.04, p < 0.0001), and decreased over time (aORper-1-year-increase  = 0.99, 95% CI: 0.98-1.00, p = 0.0093). Evaluating possible modifiable risk factors in the exploratory analysis, the probability of DR increased with higher HbA1c (aORper-1-mmol/mol-increase-in-HbA1c  = 1.03, 95% CI: 1.03-1.03, p < 0.0001) and was higher among individuals with hypertension (aOR = 1.24, 95% CI: 1.11-1.38, p < 0.0001) and smokers (aOR = 1.30, 95% CI: 1.17-1.44, p < 0.0001).

CONCLUSIONS

The prevalence of DR in this large cohort of youth with T1D varied among countries, increased with diabetes duration, decreased over time, and was associated with higher HbA1c, hypertension, and smoking.

Smoking and diabetes interplay: A comprehensive review and joint statement

Evidence shows that smoking increases the risk of pre-diabetes and diabetes in the general population. Among persons with diabetes, smoking has been found to increase the risk of all-cause mortality and aggravate chronic diabetic complications and glycemic control. The current paper, which is a joint position statement by the French-Speaking Society on Tobacco (Société Francophone de Tabacologie) and the French-Speaking Society of Diabetes (Société Francophone du Diabète), summarizes the data available on the association between smoking and diabetes and on the impact of smoking and smoking cessation among individuals with type 1, type 2, and gestational diabetes mellitus. It also provides evidence-based information about the pharmacological and behavioral strategies for smoking cessation in these patients.

Automated Diabetic Retinopathy Detection Using Horizontal and Vertical Patch Division-Based Pre-Trained DenseNET with Digital Fundus Images

Diabetic retinopathy (DR) is a common complication of diabetes that can lead to progressive vision loss. Regular surveillance with fundal photography, early diagnosis, and prompt intervention are paramount to reducing the incidence of DR-induced vision loss. However, manual interpretation of fundal photographs is subject to human error. In this study, a new method based on horizontal and vertical patch division was proposed for the automated classification of DR images on fundal photographs. The novel sides of this study are given as follows. We proposed a new non-fixed-size patch division model to obtain high classification results and collected a new fundus image dataset. Moreover, two datasets are used to test the model: a newly collected three-class (normal, non-proliferative DR, and proliferative DR) dataset comprising 2355 DR images and the established open-access five-class Asia Pacific Tele-Ophthalmology Society (APTOS) 2019 dataset comprising 3662 images. Two analysis scenarios, Case 1 and Case 2, with three (normal, non-proliferative DR, and proliferative DR) and five classes (normal, mild DR, moderate DR, severe DR, and proliferative DR), respectively, were derived from the APTOS 2019 dataset. These datasets and these cases have been used to demonstrate the general classification performance of our proposal. By applying transfer learning, the last fully connected and global average pooling layers of the DenseNet201 architecture were used to extract deep features from input DR images and each of the eight subdivided horizontal and vertical patches. The most discriminative features are then selected using neighborhood component analysis. These were fed as input to a standard shallow cubic support vector machine for classification. Our new DR dataset obtained 94.06% and 91.55% accuracy values for three-class classification with 80:20 hold-out validation and 10-fold cross-validation, respectively. As can be seen from steps of the proposed model, a new patch-based deep-feature engineering model has been proposed. The proposed deep-feature engineering model is a cognitive model, since it uses efficient methods in each phase. Similar excellent results were seen for three-class classification with the Case 1 dataset. In addition, the model attained 87.43% and 84.90% five-class classification accuracy rates using 80:20 hold-out validation and 10-fold cross-validation, respectively, on the Case 2 dataset, which outperformed prior DR classification studies based on the five-class APTOS 2019 dataset. Our model attained about >2% classification results compared to others. These findings demonstrate the accuracy and robustness of the proposed model for classification of DR images.

Prevalence, characteristics and risk factors of diabetic retinopathy in type 2 diabetes mellitus patients in Jordan: a cross-sectional study

Objectives

To measure the prevalence of diabetic retinopathy in patients with type 2 diabetes, to define their characteristics, and identify the associated risk factors.

Methods

We performed a cross sectional study of 1316 adult patients with type 2 diabetes mellitus who attended an ophthalmology clinic. Demographic, clinical, and laboratory data were analyzed. Diabetic retinopathy (DR) was diagnosed using a complete ophthalmic evaluation, including a fundic examination. Two regression models were constructed to identify the risk factors associated with DR and the parameters associated with the stage of retinopathy.

Results

Men accounted for 774 (58.8%) of the participants. The prevalence of DR was 28.2% (371 participants). DR was significantly more common in participants who were ≥60 years old, were women, had had diabetes for >10 years, were taking insulin, were not taking metformin, had a body mass index >30 kg/m², were current smokers, or had a history of hypertension. Advanced stages of DR were more common in participants in the later stages of nephropathy and with albuminuria.

Conclusions

Poor glycemic control, smoking, and advanced diabetic kidney disease are most closely associated with retinopathy. Further longitudinal studies are necessary to identify the mechanisms underlying these relationships and to guide community-based interventions.

Risk Factors of Microvascular Complications Among Type 2 Diabetic Patients Using Cox Proportional Hazards Models: A Cohort Study in Tabuk Saudi Arabia

Purpose

The burden of type 2 diabetes (T2D) is high in Saudi Arabia, but data related to its complications are limited. This study aimed to determine the incidence of microvascular complications caused by T2D and evaluate the impact of the associated risk factors.

Patients and Methods

This retrospective cohort study was conducted at two military hospitals in Tabuk, Saudi Arabia. Data on the socio-demographics, glycaemic profile, blood lipid indices, duration of T2D, and associated microvascular complications were collected from electronic health records and medical files. Descriptive statistics and Cox proportional hazards models were used for data analysis.

Results

This study included 1563 T2D patients. The incidence of microvascular complications was 34.3% (95% confidence interval [CI], 32.0-36.6). Retinopathy was the most common complication (incidence=20.0%; 95% CI, 18.0-22.0%), while nephropathy was the least common complication (incidence=12.2%; 95% CI, 10.6-13.8%). Advanced age (≥65 years) showed the highest risk of retinopathy (Hazard ratios [HR], 2.86; 95% CI, 2.56-3.21), neuropathy (HR, 2.70; 95% CI, 2.40-3.05), and nephropathy (HR, 2.37; 95% CI, 2.12-2.64) compared with their counterparts. After adjusting for potential confounders, the study found that the significant risk factors for microvascular complications were longer duration (≥10 years) of T2D (HR, 5.3; 95% CI, 5.1-5.6), uncontrolled hypertension (HR, 3.9; 95% CI, 3.3-4.2), poor glycaemic control (HR, 4.6; 95% CI, 4.3-5.1), obesity (HR, 2.3; 95% CI, 2.2-2.6), and dyslipidaemia (HR, 1.6; 95% CI, 1.2-2.0).

Conclusion

Given the high burden of microvascular complications in military healthcare facilities in Tabuk, Saudi Arabia, a context-specific accessible public health program focusing on the promotion of a healthy lifestyle, physical activity, and consumption of a healthy diet, as well as the early diagnosis and management of diabetes, needs to be developed and implemented.

Effects of Smoking on Outcomes of Anti-Vascular Endothelial Growth Factor Therapy in Patients with Diabetic Macular Edema: A Retrospective Case-Control Study

PURPOSE

To determine the effect of smoking on the response to anti-vascular endothelial growth factor (anti-VEGF) therapy treatment in patients with diabetic macular edema (DME).

METHODS

This is a retrospective case - control study that included 60 eyes with DME. Smoking habits were obtained from hospital records and patient recall. Patients were divided into two groups: the ever-smoker group and the never-smoker group. All patients received Intravitreal ranibizumab with three loading doses followed by PRN protocol and all were followed up for at least 1 year. Outcome measures were best-corrected visual acuity (BCVA), central retinal thickness (CRT) at the fovea, and number of visits.

RESULTS

Smoking was not associated with worse posttreatment visual acuity and was not found to influence the change in ocular coherence tomography measurement of central macular thickness and the change in BCVA (posttreatment minus pretreatment). There were no statistically significant differences in the duration of treatment or number of visits between two groups of patients the ever-smoker group and the never-smoker group (P > 0.05).

CONCLUSION

In this study, smoking status did not influence the treatment outcome of anti-VEGFs; however, smoking should be encouraged due to its well-known other systemic unwanted effects.

Impact of stopping smoking on metabolic parameters in diabetes mellitus: A scoping review

The purpose of this scoping review is to create a single narrative that describes the impact of smoking cessation on metabolic parameters in people with diabetes. It is generally well accepted that smoking enhances the harmful effects of elevated blood glucose levels, accelerating the vascular damage seen in patients with diabetes. Smoking cessation has clear benefits in terms of reducing cardiovascular morbidity and mortality. However, there is less evidence for the impact of smoking cessation on other diabetes-related complications. Studies in people with diabetes have shown improvement as well as temporary deterioration in glycemic control after ceasing smoking. Only a few studies have described the effect of quitting smoking on insulin resistance and lipid parameters, however, their results have been inconclusive. In this situation, healthcare professionals should not assume that cessation of smoking will improve metabolic parameters in patients with diabetes. It seems they should, first of all, emphasize the prevention of weight gain that may be associated with quitting smoking. The lack of data regarding the metabolic effects of smoking and smoking cessation in diabetes is very disappointing and this area needs to be addressed.

Associations between diabetic retinopathy and modifiable risk factors: An umbrella review of meta-analyses

AIMS

Several modifiable risk factors have been meta-analysed for diabetic retinopathy (DR), such as physical activity and vitamin D status. To date, these factors have not been systematically aggregated and the credibility of evidence assessed. Therefore, the aim of this umbrella review was to aggregate all modifiable risks of DR and assess the credibility of the evidence.

METHODS

An umbrella review of meta-analyses was undertaken. For each meta-analytic association, random-effects effect size, 95% confidence intervals (CIs), heterogeneity, small-study effects, excess significance bias and 95% prediction intervals were calculated. The credibility of significant evidence (p < 0.05) was graded from I to IV, using pre-defined criteria.

RESULTS

After initial searches, 13 studies were included covering 34 independent outcomes (total participants = 824,372). Positive associations were found between insulin usage and diabetic macular oedema (RR = 4.5; 95% CI 3.1-6.6), and DR risk (RR = 2.3; 95% CI 1.4-3.9) in people with type 2 diabetes. Vitamin D deficiency was associated with DR risk (OR = 2.8; 95% CI 1.1-7.1), as was obesity (RR = 1.34; 95% CI 1.06-1.68) and sedentary behaviour (RR = 1.22; 95%CI 1.03-1.44). Intensive blood pressure targets (RR = 0.8 95%CI 0.8-1.0), and moderate physical activity (RR = 0.69; 95%CI 0.53-0.91) yielded significant protective associations with DR.

CONCLUSIONS

People with type 2 diabetes on insulin have a high risk of macular oedema and DR. Vitamin D deficiency yielded almost three times greater odds of DR, while intensive blood pressure control reduces DR risk by 20% and moderate physical activity by 31%. Healthcare professionals should use this evidence to identify those people most at risk to ensure that proper treatment and healthy lifestyles are recommended.

Correlation between the progression of diabetic retinopathy and inflammasome biomarkers in vitreous and serum – a systematic review

Activation of the NOD-like receptor protein 3 (NLRP3) inflammasome pathway has been implicated in Diabetic retinopathy (DR) pathogenesis, but its impact on DR development and progression remains unclear. Therefore, the primary aim of this systematic literature review was to determine the role of the inflammasome in DR development. Furthermore, the secondary aim was to determine whether systemic inflammasome activity can be used to predict DR progression. Studies measuring vitreous and/or serum inflammasome biomarkers in DR patients with Type 2 Diabetes Mellitus (T2DM) were searched systematically using online databases EMBASE, PubMed and Web of Science with the last search conducted on 29^th of September 2021. The risk of bias was assessed using the Newcastle Ottawa Scale and 20 studies were eligible for narrative analysis. Limitations included the heterogeneity in detection assays used, the small and uneven sample size, a lack of vitreous data in earlier disease stages, and not accounting for patients with other systemic co-morbidities. Analysis showed that inflammasome biomarkers IL-1β and IL-18 increased significantly from non-proliferative DR to proliferative DR in both vitreous and serum, suggesting the inflammasome pathway is activated as DR progresses and that serum inflammasome levels could be explored as potential biomarkers for DR progression.

Association of cigarette smoking with retinal capillary plexus: an optical coherence tomography angiography study

PURPOSE

To investigate the association between cigarette smoking and retinal capillary plexus (RCP) using optical coherence tomography angiography (OCTA) and to examine whether potential vascular risk factors could impact their association.

METHODS

This is a cross-sectional, community-based study. The Jidong Eye Cohort Study included participants aged ≥18 years in the Jidong community (Tangshan city, northern China) from August 2019 to January 2020. All participants underwent comprehensive ophthalmic examination and completed detailed smoking questionnaires. Retinal vessel density in the superficial and deep RCP was automatically measured using OCTA.

RESULTS

Of the 2598 participants included in the study, 2026 (78.0%) never smoked and 572 (22.0%) had a history of smoking (494 [19.0%] current smokers and 78 [3.0%] former smokers). The median (interquartile range) age was 41 (34-52) years for the non-smoking group and 45 (35-54.5) years for the smoking group. Multivariable analysis showed that smoking history is associated with a low deep RCP vessel density in the parafovea (β, -0.53; 95% confidence interval [CI], -0.82 to -0.24) and four quadrants. Increased smoking pack-years were associated with reduced deep RCP vessel density in the parafovea (p for trend <0.001) and four quadrants. The significant interaction between diabetes and smoking only was found for superficial RCP vessel density in the parafovea (p for interaction = 0.014) and four quadrants except for the temporal quadrants.

CONCLUSIONS

Cigarette smoking is an independent risk factor for reduced deep RCP vessel density. Our findings imply the potential detrimental effect of smoking on the occurrence of ocular diseases.

Food Insecurity and Vision Impairment Among Adults Age 50 and Older in the United States

PURPOSE

To test the hypothesis that food insecurity is associated with greater prevalence of vision impairment (VI).

DESIGN

Cross-sectional, nationally representative survey of US adults.

METHODS

Adults 50 years and older were included. Food security category (ie, full, marginal, low, or very low) was assessed by the US Household Food Security Survey Module. Objective presenting VI (PVI) and self-reported VI (SRVI) were assessed by examination and survey, respectively. Separate logistic regression models were constructed with food insecurity category as a predictor of PVI or SRVI. Models were adjusted for age, gender, race, education, income, cigarette use, alcohol use, body mass index, and physical activity. Age-stratified analyses (age 50 through 64 years vs 65 years and older) were also conducted.

RESULTS

Mean age of participants (n = 10,078) was 63.4 years; 8,518 (89.9%) were fully food secure, 1,033 (7.2%) had PVI, and 2,633 (20.1%) had SRVI. Compared with full food security, adjusting for sociodemographic confounders, those with marginal (adjusted odds ratio [aOR], 1.31; 95% CI, 0.97-1.76), low (aOR, 1.61; 95% CI, 1.17-2.23), and very low (aOR, 2.71; 95% CI, 1.75-4.20) food security had higher odds of PVI. Compared with full food security, those with marginal (aOR, 1.58; 95% CI, 1.23-2.02), low (aOR, 1.46; 95% CI, 1.11-1.92), and very low (aOR, 1.85; 95% CI, 1.41-2.41) food security had higher odds of SRVI. The associations between food insecurity and PVI were greater in magnitude in those 65 years and older compared with those age 50 through 64 years.

CONCLUSIONS

In this nationally representative sample of US adults 50 years and older, severe food insecurity was increasingly associated with greater prevalence of VI in a dose-response manner.

The Effect of Diet and Lifestyle on the Course of Diabetic Retinopathy-A Review of the Literature

Diabetes is a major social problem. As shown by epidemiological studies, the world incidence of diabetes is increasing and so is the number of people suffering from its complications. Therefore, it is important to determine possible preventive tools. In the prevention of diabetic retinopathy, it is essential to control glycemia, lipid profile and blood pressure. This can be done not only by pharmacological treatment, but first of all by promoting a healthy lifestyle, changing dietary habits and increasing physical activity. In our work, we present a review of the literature to show that physical exercise and an adequate diet can significantly reduce the risk of diabetes and diabetic retinopathy.

Longitudinal Associations Between Vision Impairment and the Incidence of Neuropsychiatric, Musculoskeletal, and Cardiometabolic Chronic Diseases

PURPOSE

To compare the incidence and hazard of neuropsychiatric, musculoskeletal, and cardiometabolic conditions among adults with and without vision impairment (VI).

DESIGN

Retrospective cohort study.

METHODS

The sample comprised enrollees in a large private health insurance provider in the United States, including 24 657 adults aged ≥18 years with VI and age- and sex-matched controls. The exposure variable, VI, was based on low vision and blindness International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification (ICD-9-CM and ICD-10-CM), diagnosis codes. Physician-diagnosed incident neuropsychiatric, musculoskeletal, and cardiometabolic diseases were identified using ICD codes. Separate Cox proportional hazards regression models were used to assess the association of VI with incidence of 30 chronic conditions, adjusting for Elixhauser Comorbidity Index. Analyses were stratified by age 18-64 years and ≥65 years.

RESULTS

In individuals with VI aged 18-64 years (n=7478), the adjusted hazard of neuropsychiatric (HR 2.1, 95% CI 1.9, 2.4), musculoskeletal (HR 1.8, 95% CI 1.7, 2.0), and cardiometabolic (HR 1.8, 95% CI 1.7, 2.0) diseases was significantly greater than in matched controls (mean 5.5 years follow-up). Similar associations were seen between patients with VI aged ≥65 years (n=17 179) for neuropsychiatric (HR 2.4, 95% CI 2.1, 2.7), musculoskeletal (HR 1.8, 95% CI 1.6, 1.9), and cardiometabolic (HR 1.7, 95% CI 1.4, 2.0) diseases. VI was associated with a higher hazard of each of the 30 conditions we assessed, with similar results in both age cohorts.

CONCLUSION

Across the life span, adults with VI had an approximately 2-fold greater adjusted hazard for common neuropsychiatric, musculoskeletal, and cardiometabolic disorders compared with matched controls without VI.

Tobacco use patterns and clinical outcomes in the T1D exchange

AIMS

This study examined associations between tobacco use and diabetes outcomes using the T1D Exchange Registry.

METHODS

Adult participants (N = 933) completed standardized questionnaires including self-reported outcomes: past year serious hypoglycemic and diabetic ketoacidosis episodes, diabetes self-care, diabetes distress, and self-monitoring of blood glucose. Chart-extracted outcomes included HbA1c, nephrology and neuropathy diagnoses, and BMI. We examined the relation of tobacco use status (never, former, current) and frequency of use (daily versus less than daily) to these outcomes.

RESULTS

The majority had never used tobacco (55%, n = 515); 27% (n = 252) were former users and 18% (n = 166) were current users (with 31% using daily). Tobacco status was associated with HbA1c, BMI, self-care, distress, and blood glucose monitoring frequency. Across most outcomes, current users evidenced worse values relative to never users, and former users were largely similar to never users. Daily use was associated with significantly worse outcomes on HbA1c, diabetes self-care, and distress scores relative to less than daily use.

CONCLUSIONS

These cross-sectional comparisons suggest that current tobacco use is associated with worse status on important clinical diabetes indicators. Former users did not evidence these deleterious associations. Findings point to potential diabetes-specific motivators that could inform tobacco cessation interventions.

Identification of Silent Myocardial Ischemia in Patients with Long-Term Type 1 and Type 2 Diabetes

(1) Background: This study aimed to analyze epidemiological data to identify risk factors for silent myocardial ischemia in patients with long-term type 1 and type 2 diabetes. (2) Methods: An analysis was performed on 104 patients with long-term type 1 and type 2 diabetes who had not previously been diagnosed with cardiovascular disease. During hospitalization, patients were subjected to a standard ECG exercise test on a treadmill. If the test could not be performed or the result was uncertain, a pharmacological exercise test with dobutamine was performed. In the case of a positive exercise ECG test or a positive dobutamine test, the patient underwent coronary angiography. (3) Results: Atherosclerotic lesions were found in 24 patients. Patients with silent ischemia were significantly older and had a lower mean left ventricular ejection fraction and a higher incidence of carotid atherosclerosis. The presence of microvascular complications did not increase the risk of silent ischemia. (4) Conclusions: Silent heart ischemia is more common in type 2 than type 1 diabetes. Predisposing factors include older age, coexistence of carotid atherosclerosis, lower left ventricular ejection fraction, and smoking in patients with type 1 diabetes. Concomitant microvascular complications are not a risk factor.

The many faces of diabetes. Is there a need for re-classification? A narrative review

The alarming rise in the worldwide prevalence of obesity and associated type 2 diabetes mellitus (T2DM) have reached epidemic portions. Diabetes in its many forms and T2DM have different physiological backgrounds and are difficult to classify. Bariatric surgery (BS) is considered the most effective treatment for obesity in terms of weight loss and comorbidity resolution, improves diabetes, and has been proven superior to medical management for the treatment of diabetes. The term metabolic surgery (MS) describes bariatric surgical procedures used primarily to treat T2DM and related metabolic conditions. MS is the most effective means of obtaining substantial and durable weight loss in individuals with obesity. Originally, BS was used as an alternative weight-loss therapy for patients with severe obesity, but clinical data revealed its metabolic benefits in patients with T2DM. MS is more effective than lifestyle or medical management in achieving glycaemic control, sustained weight loss, and reducing diabetes comorbidities. New guidelines for T2DM expand the use of MS to patients with a lower body mass index.Evidence has shown that endocrine changes resulting from BS translate into metabolic benefits that improve the comorbid conditions associated with obesity, such as hypertension, dyslipidemia, and T2DM. Other changes include bacterial flora rearrangement, bile acids secretion, and adipose tissue effect.This review aims to examine the physiological mechanisms in diabetes, risks for complications, the effects of bariatric and metabolic surgery and will shed light on whether diabetes should be reclassified.

Update on Management of Non-proliferative Diabetic Retinopathy without Diabetic Macular Edema; Is There a Paradigm Shift?

Diabetic retinopathy (DR) is the major cause of visual impairment and blindness in the working-age population. Conventional management for nonproliferative diabetic retinopathy (NPDR) without diabetic macular edema (DME) is derived from the findings of the Early Treatment Diabetic Retinopathy Study (ETDRS). Although the ETDRS protocol basically includes observation, selected cases of severe NPDR may undergo scatter laser photocoagulation. Post-hoc analysis of recent trials has shown that patients with NPDR receiving intravitreal anti-vascular endothelial growth factor (anti-VEGF) for DME would experience improvement in the DR severity scale (DRSS). In addition, recent randomized trials (PANORAMA and Protocol W) have revealed that early intervention with intravitreal aflibercept in eyes with moderately severe to severe NPDR is associated with significant improvement in DRSS and reduced vision-threatening complications of DR. Based on recent studies, it seems that the therapeutic approach to NPDR may undergo a substantial change and a paradigm shift toward considering early intervention with the administration of intravitreal anti-VEGF injections. However, the long-term results and the duration of adherence to anti-VEGF therapy for eyes with NPDR are not yet defined. It is also not apparent whether improvement in DRSS is a true disease modification. Studies showed that DRSS improvement is not associated with retinal reperfusion. In addition, DRCR.net Protocol W showed no visual acuity benefit with the early intravitreal aflibercept injection in moderate to severe NPDR as compared with performing observation plus intravitreal aflibercept applied only after progression to proliferative DR or vision-impairing DME. The cost-benefit ratio is also a challenge. Herein, we look at different aspects of early anti-VEGF application and discuss its pros and cons in the process of treating NPDR.

Diabetic retinopathy risk in patients with unhealthy lifestyle: A Mendelian randomization study

PURPOSE

This study aimed to investigate the causal association between unhealthy lifestyle factors and diabetic retinopathy (DR) risk and to determine better interventions targeting these modifiable unhealthy factors.

DESIGN

Two-sample Mendelian randomization (MR) analysis was performed in this study. The inverse variance-weighted method was used as the primary method.

METHOD

Our study included 687 single-nucleotide polymorphisms associated with unhealthy lifestyle factors as instrumental variables. Aggregated data on individual-level genetic information were obtained from the corresponding studies and consortia. A total of 292,622,3 cases and 739,241,18 variants from four large consortia (MRC Integrative Epidemiology Unit [MRC-IEU], Genetic Investigation of Anthropometric Traits [GIANT], GWAS & Sequencing Consortium of Alcohol and Nicotine Use [GSCAN], and Neale Lab) were included.

RESULT

In the MR analysis, a higher body mass index (BMI) (odds ratio [OR], 95% confidence interval [CI] = 1.42, 1.30-1.54; P < 0.001] and cigarettes per day (OR, 95% CI = 1.16, 1.05-1.28; P = 0.003) were genetically predicted to be causally associated with an increased risk of DR, while patients with higher hip circumference (HC) had a lower risk of DR (OR, 95% CI = 0.85, 0.76-0.95; P = 0.004). In the analysis of subtypes of DR, the results of BMI and HC were similar to those of DR, whereas cigarettes per day were only related to proliferative DR (PDR) (OR, 95% CI = 1.18, 1.04-1.33; P = 0.009). In the MR-PRESSO analysis, a higher waist-to-hip ratio (WHR) was a risk factor for DR and PDR (OR, 95% CI = 1.24, 1.02-1.50, P = 0.041; OR, 95% CI = 1.32, 1.01-1.73, P = 0.049) after removing the outliers. Furthermore, no pleiotropy was observed in these exposures.

CONCLUSION

Our findings suggest that higher BMI, WHR, and smoking are likely to be causal factors in the development of DR, whereas genetically higher HC is associated with a lower risk of DR, providing insights into a better understanding of the etiology and prevention of DR.

Incidence and Risk Factors for Progression to Diabetes Mellitus: A Retrospective Cohort Study

(1) Objective: This study examined the incidence and risk factors contributing to the progression to diabetes mellitus (DM) in a seven-year follow-up study of non-diabetic National Health Examinees. (2) Methods: For this retrospective observational cohort study, we used two national representative databases: the National Health Screening (HEALS) database 2009 and the National Health Insurance Service (NHIS) database 2009-2015. The eligible subjects without DM with blood sugar levels of <126 mg/dL were selected using the HEALS database. The subsequent follow-up and clinical outcomes were evaluated using the NHIS database. Cox proportional hazard regression was applied to examine the effects of the covariates on progression to diabetes. (3) Results: Among those who took part in the national health screening in 2009, 4,205,006 subjects who met the eligibility criteria were selected. Of these, 587,015 were diagnosed with DM during the follow-up by 2015. The incidence of progression from non-diabetes to DM was 14.0%, whereas that from impaired fasting glucose (IFG) to DM was 21.9%. Compared to the normal group, the newly diagnosed DM group was more likely to comprise older, female, currently smoking, and high-risk drinking participants and participants with IFG, hypertension, dyslipidemia, and metabolic syndrome. (4) Conclusions: This epidemiological study in the Republic of Korea found risk factors similar to those of other studies, but the incidence of progression to DM was 22.8 per 1000 person-years, which is higher than that previously reported. Hence, more care is needed to prevent DM.

Incidence of Proliferative Diabetic Retinopathy and Other Neovascular Sequelae at 5 Years Following Diagnosis of Type 2 Diabetes

OBJECTIVE

To determine the incidence and risk factors for developing proliferative diabetic retinopathy (PDR), tractional retinal detachment (TRD), and neovascular glaucoma (NVG) at 5 years after the initial diagnosis of type 2 diabetes.

RESEARCH DESIGN AND METHODS

Insured patients aged ≥18 years with newly diagnosed type 2 diabetes and 5 years of continuous enrollment were identified from a nationwide commercial claims database containing data from 2007 to 2015. The incidences of PDR, TRD, and NVG were computed at 5 years following the index diagnosis of type 2 diabetes. Associations between these outcomes and demographic, socioeconomic, and medical factors were tested with multivariable logistic regression.

RESULTS

At 5 years following the initial diagnosis of type 2 diabetes, 1.74% (1,249 of 71,817) of patients had developed PDR, 0.25% of patients had developed TRD, and 0.14% of patients had developed NVG. Insulin use (odds ratio [OR] 3.59, 95% CI 3.16-4.08), maximum HbA1c >9% or >75 mmol/mol (OR 2.10, 95% CI 1.54-2.69), renal disease (OR 2.68, 95% CI 2.09-3.42), peripheral circulatory disorders (OR 1.88, 95% CI 1.25-2.83), neurological disease (OR 1.62, 95% CI 1.24-2.11), and older age (age 65-74 years) at diagnosis (OR 1.62, 95% CI 1.28-2.03) were identified as risk factors for development of PDR at 5 years. Young age (age 18-23 years) at diagnosis (OR 0.46, 95% CI 0.29-0.74), Medicare insurance (OR 0.60, 95% CI 0.70-0.76), morbid obesity (OR 0.72, 95% CI 0.59-0.87), and smoking (OR 0.84, 95% CI 0.70-1.00) were identified as protective factors.

CONCLUSIONS

A subset of patients with type 2 diabetes develop PDR and other neovascular sequelae within the first 5 years following the diagnosis with type 2 diabetes. These patients may benefit from increased efforts for screening and early intervention.

Incidence and risk factors of severe non-proliferative/proliferative diabetic retinopathy: More than a decade follow up in the Tehran Lipids and Glucose Study

Aims/Introduction

To examine the incidence rate of severe non‐proliferative and proliferative diabetic retinopathy (severe‐NPDR/PDR) and determine its potential risk factors.

Materials and Methods

The study consisted of 1,169 participants (675 women) with type 2 diabetes mellitus, aged ≥20 years. A trained interviewer collected information about the history of pan‐retinal photocoagulation as a result of diabetic retinopathy. Multivariable Cox proportional hazards regression models were applied.

Results

We found 187 cases (126 women) of severe‐NPDR/PDR during a median follow‐up period of 12.7 years; the corresponding incidence rate was 13.6 per 1,000 person‐years. Being overweight (hazard ratio [HR], 95% confidence interval [CI] 0.60, 0.39–0.92) and obese (HR 0.48, 95% CI 0.27–0.83) were associated with lower risk, whereas being smoker (HR 1.75, 95% CI 1.12–2.74), having fasting plasma glucose levels 7.22–10.0 mmol/L (HR 2.81, 95% CI 1.70–4.62), fasting plasma glucose ≥10 mmol/L (HR 5.87, 95% CI 3.67–9.41), taking glucose‐lowering medications (HR 2.58, 95% CI 1.87–3.56), prehypertension status (HR 1.65, 95% CI 1.05–2.58) and newly diagnosed hypertension (HR 1.96, 95% CI 1.06–3.65) increased the risk of severe‐NPDR/PDR. Among newly diagnosed diabetes patients, being male was associated with a 59% lower risk of severe‐NPDR/PDR (HR 0.41, 95% CI 0.21–0.79). Furthermore, patients who had an intermediate level of education (6–12 years) had a higher risk of developing PDR (HR 1.86, 95% CI 1.05–3.30) compared with those who had <6 years of education.

Conclusions

Among Iranians with type 2 diabetes mellitus, 1.36% developed severe‐NPDR/PDR annually. Normal bodyweight, being a smoker, out of target fasting plasma glucose level, prehypertension and newly diagnosed hypertension status were independent risk factors of severe‐NPDR/PDR. Regarding the sight‐threatening entity of advanced diabetic retinopathy, the multicomponent strategy to control diabetes, abstinence of smoking and tight control of blood pressure should be considered.

Prevalence, severity stages, and risk factors of diabetic retinopathy in 1464 adult patients with type 1 diabetes

PURPOSE

To determine the prevalence of diabetic retinopathy (DR) and its risk factors in adult type 1 diabetes (T1D) patients METHODS: In this cross-sectional study, all T1D patients followed in the University Center for Diabetes and its Complications of Lariboisière Hospital (Paris, France) between January 2017 and February 2019 were included. Ophthalmologic and systemic data were collected from electronic records. The association between DR (and each grade) and associated factors were estimated by univariate and multivariate analyses using logistic regression models.

RESULTS

A total of 1464 patients (46.2% of women, mean age: 42.2 ± 15.8 years) were included. The mean hemoglobin A1c (HbA1c) was 7.8 ± 1.7% and the mean diabetes duration was 20.5 ± 13.5 years. DR prevalence was 50.1% (47.4-52.6) and the prevalence of mild, moderate, and severe non-proliferative DR and proliferative DR was 19.1%, 9.4%, 3.9%, and 17.6%, respectively. DR was significantly associated with male gender, an older age, former and current smoking status, a higher BMI, the presence of nephropathy and neuropathy, higher HBA1c, and longer diabetes duration. Patients with HbA1c > 10% had an adjusted odds ratio (OR) of 3.25 (1.77-6.01) of having DR compared to patients with HbA1c < 6.5%. Patients with a diabetes duration > 30 years had an adjusted OR of 24.87 (14.82-42.67) higher of having DR compared to patients with a diabetes duration < 10 years.

CONCLUSION

In this study, 50.1% of adult T1D patients had DR and 17.6% had proliferative DR. Diabetes duration and HbA1c were major risk factors.

Association between smoking history and optical coherence tomography angiography findings in diabetic patients without diabetic retinopathy

Purpose

To investigate any associations between cigarette smoking and retinal microvascular changes in diabetic patients without visible retinopathy.

Design

Retrospective, cross-sectional study.

Participants

1099 eyes from 1099 diabetic patients with no clinical evidence of diabetic retinopathy (DR) were included in this study.

Methods

Diabetic patients underwent optical coherence tomography angiography (OCTA) scanning at Zuckerberg San Francisco General Hospital and Trauma Center between April 2018 and September 2019. Patient demographic and clinical information was collected. Standard bivariate statistics and multivariate linear regression were performed.

Main outcome measures

OCTA parameters included metrics related to the foveal avascular zone (FAZ; area, perimeter, circularity), perfusion density (PD; full, center, inner), and vessel length density (VLD; full, center, inner).

Results

The study population included 750 non-smokers and 349 smokers. FAZ perimeter was the only OCTA parameter that was significantly different between the two groups on uncontrolled analysis (P = 0.033). Multivariate regression analyses revealed significant associations between lower VLD full (β = -0.31, P = 0.048), lower VLD inner (β = -0.35, P = 0.046) and a history of smoking. No significant associations between cigarette smoking and either FAZ or PD were detected.

Conclusions

Our results suggest that smoking is likely associated with deleterious changes in the retinal microvasculature of patients with a history of diabetes and no visible DR. Based on these findings, diabetic patients with a history of smoking may benefit from higher prioritization in terms of ophthalmic screening.

Construction of a knowledge graph for diabetes complications from expert-reviewed clinical evidences

A knowledge graph is a structured representation of data that can express entity and relational knowledge. More attention has been paid to the study of a clinical knowledge graph, especially in the field of chronic diseases. However, knowledge graph construction is based mainly on electronic medical records and other data sources, and the authority of the constructed knowledge graph presents some problems. Therefore, regarding the quality of evidence, this study, in combination with experimental research on system evaluation and meta-analysis presents some new information, On the basis of evidence-based medicine (EBM), the secondary results of systematic evaluation and meta-analyses of social, psychological, and behavioral aspects were extracted as data for the core nodes and edges of a knowledge graph to construct a graph of type 2 diabetes (T2D) and its complications. In this study, relevant life-style evidence that are factors for the risk of diabetic retinopathy (DR), diabetic nephropathy (DN), diabetic foot (DF), and diabetic depression (DD), and the results of several of the relevant clinical test, including bariatric surgery, myopia, lipid-lowering drugs, lipid-lowering drug duration, blood glucose control, disease course, glycosylated hemoglobin, fasting blood glucose, hypertension, sex, smoking and other common lifestyle characteristics were finally extracted. The evidence-based knowledge graph of the DM complications was constructed by extracting relevant disease, risk factors, risk outcomes, and other diabetes entities and the strength of the data for the odds ratio (OR) or relative risk (RR) correlations from clinical evidence. Moreover, the risk prediction models constructed using a logistic model were incorporated into the knowledge graph to visualize the risk score of DM complications for each user. In short, the EBM-powered construction of the knowledge graph could provide high-quality information to support decisions for the prevention and control of diabetes and its complications.

Diabetic retinopathy in newly diagnosed Type 2 diabetes mellitus: Prevalence and predictors of progression; a national primary network study

AIMS

To determine, inreal-world primary care settings, the prevalence of, and risk factors for, retinopathy atType 2 diabetes mellitus diagnosis and report cumulative incidence and progression of retinopathy seven years after diabetes diagnosis.

METHODS

Retrospective cohort analysis of people with newly diagnosed Type 2 diabetesrecorded bythe Royal College of General Practitioners Research and Surveillance Centre(between 2005 and 2009, n=11,399).Outcomes included; retinopathy prevalence atdiabetesdiagnosis (baseline) and cumulative incidence or progression of retinopathy at seven years. Retinopathy prevalence was compared with the United Kingdom Prospective Diabetes Study (UKPDS-1998). Factors influencing retinopathy incidence and progression were analysed using logistic regression.

RESULTS

Baseline retinopathy prevalencewas 18% (n=2,048) versus 37% in UKPDS. At seven years, 11.6% (n=237) of those with baseline retinopathyhad progression of retinopathy. In those without baseline retinopathy, 46.4% (n=4,337/9,351) developed retinopathy by seven years. Retinopathy development (OR: 1.05 [95%CI: 1.02-1.07] per mmol/mol increase) and progression (OR: 1.05 [1.04-1.06]) at seven years was associated with higher HbA_1catdiabetesdiagnosis. Obesity (OR: 0.88 [0.79-0.98]) and high socioeconomic status (OR: 0.63 [0.53-0.74]) were negatively associated with retinopathy development at seven years.

CONCLUSIONS

Baseline retinopathy prevalence has declined since UKPDS. Additionally, HbA_1c at diabetes diagnosis remains important for retinopathy development and progression.

Risk of Typical Diabetes-Associated Complications in Different Clusters of Diabetic Patients: Analysis of Nine Risk Factors

Objectives: Diabetic patients are often diagnosed with several comorbidities. The aim of the present study was to investigate the relationship between different combinations of risk factors and complications in diabetic patients. Research design and methods: We used a longitudinal, population-wide dataset of patients with hospital diagnoses and identified all patients (n = 195,575) receiving a diagnosis of diabetes in the observation period from 2003–2014. We defined nine ICD-10-codes as risk factors and 16 ICD-10 codes as complications. Using a computational algorithm, cohort patients were assigned to clusters based on the risk factors they were diagnosed with. The clusters were defined so that the patients assigned to them developed similar complications. Complication risk was quantified in terms of relative risk (RR) compared with healthy control patients. Results: We identified five clusters associated with an increased risk of complications. A combined diagnosis of arterial hypertension (aHTN) and dyslipidemia was shared by all clusters and expressed a baseline of increased risk. Additional diagnosis of (1) smoking, (2) depression, (3) liver disease, or (4) obesity made up the other four clusters and further increased the risk of complications. Cluster 9 (aHTN, dyslipidemia and depression) represented diabetic patients at high risk of angina pectoris “AP” (RR: 7.35, CI: 6.74–8.01), kidney disease (RR: 3.18, CI: 3.04–3.32), polyneuropathy (RR: 4.80, CI: 4.23–5.45), and stroke (RR: 4.32, CI: 3.95–4.71), whereas cluster 10 (aHTN, dyslipidemia and smoking) identified patients with the highest risk of AP (RR: 10.10, CI: 9.28–10.98), atherosclerosis (RR: 4.07, CI: 3.84–4.31), and loss of extremities (RR: 4.21, CI: 1.5–11.84) compared to the controls. Conclusions: A comorbidity of aHTN and dyslipidemia was shown to be associated with diabetic complications across all risk-clusters. This effect was amplified by a combination with either depression, smoking, obesity, or non-specific liver disease.

Cardiometabolic Risk Factors leading to Diabetes Mellitus among the Young (YOD) from the 8th Philippine National Nutrition Survey

Objectives

This study looked into the prevalence of diabetes mellitus (DM) and risks for cardiovascular and metabolic diseases among young adults with diabetes (age 20-44 years old, YOD) and late-onset DM (≥45 years old, LOD) in Filipinos.

Methodology

Weighted data from 546,580 adults with DM from the 8^th Philippine National Nutrition and Health Survey (NNHeS) were utilized. Differences in sociodemographic, anthropometric, clinical profiles and metabolic risks were compared between YOD and LOD.

Results

The aggregated prevalence of DM is 5.43% (95%CI, 5.10–5.79), YOD were 2.64% (95% CI, 2.32–3.00) and LOD 9.85% (95%CI, 9.18–10.56). Mean age of YOD was 37,6 years, LOD 59,9 years. The YOD were mostly males (56%), with higher BMI (26.24 kg/m² vs 25 kg/m², p=0.002), lower mean SBP (122.41±19.17 mmHg vs 135.45±22.47 mmHg, p<0.001), more daily smokers (23% vs 14%), and alcoholic beverage drinkers (39% vs 31%). Physical activity was similar between groups (44% vs 51%, p=0.078). However, average total caloric intake (1776.78±758.38 kcal vs 1596.88±639.16 kcal, p=0.023) and carbohydrate intake (306.13±142.16 grams vs 270.53±104.74 g, p=0.014) were higher in YOD. Dietary carbohydrate proportions were higher than recommended (69% vs 68%) for both groups. Young Filipinos had higher risk to develop diabetes when they are obese II (22% vs 12%), current drinker (56% vs 37%), and current smoker (28% vs 18%). Eighty percent of YOD and LOD had metabolic syndrome (MetS). With every unit increase in age and fat intake, the odds of having MetS were raised by 5.4% (95%CI 1%–10%, p=0.029) and 1.6% (95%CI 0.04%-3%, p=0.044), respectively.

Conclusion

Early-onset diabetes mellitus appears to be driven by obesity, MetS and social behaviors. Modifiable risk factors can be improved early to decrease hazards to develop cardiometabolic complications.

Role of Oral Antioxidant Supplementation in the Current Management of Diabetic Retinopathy

Oxidative stress has been postulated as an underlying pathophysiologic mechanism of diabetic retinopathy (DR), the main cause of avoidable blindness in working-aged people. This review addressed the current daily clinical practice of DR and the role of antioxidants in this practice. A systematic review of the studies on antioxidant supplementation in DR patients was presented. Fifteen studies accomplished the inclusion criteria. The analysis of these studies concluded that antioxidant supplementation has a IIB level of recommendation in adult Type 1 and Type 2 diabetes mellitus subjects without retinopathy or mild-to-moderate nonproliferative DR without diabetic macular oedema as a complementary therapy together with standard medical care.

Prevalence of and Factors Associated with Diabetic Retinopathy in Patients with Diabetes Mellitus at Siriraj Hospital - Thailand's Largest National Tertiary Referral Center

PURPOSE

We aimed to determine the prevalence of and factors associated with diabetic retinopathy (DR) in patients with diabetes mellitus (DM) and to evaluate the relationship between significant factors and severity of DR.

PATIENTS AND METHODS

A retrospective cross-sectional study of 1130 diabetic patients (mean age: 60 years, 62.7% female, 91% type 2 diabetes) was conducted in the diabetes clinic of Siriraj Hospital (Bangkok, Thailand) during January 2012 to June 2015. DR was graded as absent, mild, moderate, or severe non-proliferative DR, or proliferative DR. Multivariate logistic regression analysis was used to identify independent risk factors for DR in DM patients.

RESULTS

The overall prevalence of DR was 34.78%. Multivariate analysis revealed duration of diabetes, glycated hemoglobin level (HbA_1c), presence of albuminuria, and abnormal protective sensation to be independent risk factors for DR. The prevalence of DR increased with longer duration of diabetes (p < 0.001), deterioration of glucose control (p = 0.006 for HbA_1c), presence of significant albuminuria (p = 0.010), and loss of protective sensation (p = 0.001).

CONCLUSION

In this study, one-third of DM were found to have DR. The independent predictors of DR were duration of diabetes, HbA_1c level, presence of significant albuminuria, and impaired protective sensation. Heightened awareness of these risk factors will decrease the prevalence and severity of DR, and will improve early diagnosis and treatment of DR.

Evaluation of Relevance between Advanced Glycation End Products and Diabetic Retinopathy Stages Using Skin Autofluorescence

Advanced glycation end products (AGEs) are thought to play important roles in the pathogenesis of diabetic microangiopathy, particularly in the progression of diabetic retinopathy (DR). We assessed the levels of skin autofluorescence (sAF) to assess the association between AGEs and DR stages. A total of 394 eyes of 394 Japanese subjects (172 men, 222 women; mean age ± standard deviation [SD], 68.4 ± 13.7 years) comprised the study population, i.e., subjects with diabetes mellitus (DM) (n = 229) and non-diabetic controls (n = 165). The patients with DM were divided into those without DR (NDR, n = 101) and DR (n = 128). DR included simple (SDR, n = 36), pre-proliferative (PPDR, n = 25), and PDR (n = 67). Compared to controls (0.52 ± 0.12), the AGE scores were significantly higher in patients with DM (0.59 ± 0.17, p < 0.0001), NDR (0.58 ± 0.16, p = 0.0012), and DR (0.60 ± 0.18, p < 0.0001). The proportion of patients with PDR was significantly higher in the highest quartile of AGE scores than the other quartiles (p < 0.0001). Compared to those without PDR (SDR and PPDR), those with PDR were younger (p = 0.0006), more were pseudophakic (p < 0.0001), had worse visual acuity (VA) (p < 0.0001), had higher intraocular pressure (IOP) (p < 0.0001), and had higher AGE scores (p = 0.0016). Multivariate models also suggested that younger age, male gender, pseudophakia, worse VA, higher IOP, and higher AGE scores were risk factors for PDR. The results suggested that AGE scores were higher in patients with DM and were independently associated with progression of DR. In addition, more PDR was seen in the highest quartile of AGE scores. This study highlights the clinical use of the AGE score as a non-invasive, reliable marker to identity patients at risk of sight-threatening DR.