Diabetes-Related Eye Disease Remains High in the U.S.

The number of Americans with diabetes-related eye disease remains high, according to a nationally representative sample of data from the National Health and Nutrition Examination Survey (NHANES) and other sources.

In 2021, an estimated 9.6 million Americans had diabetic retinopathy (DR) and 1.8 million had vision-threatening diabetic retinopathy (VTDR), with prevalence rates of 26.43% (95% uncertainty interval [UI] 21.95-31.60) and 5.06% (95% UI 3.90-6.57), respectively, among people living with diabetes, reported Elizabeth Lundeen, PhD, of the CDC in Atlanta, and colleagues.

Disease prevalence increased with age, with rates ranging from 13% in those younger than 25 to 28.4% in those ages 65 to 79, before declining in the oldest age group -- 25% in those 80 and older -- "likely because DR and VTDR are markers for more severe diabetes, which can lead to early mortality," they noted in JAMA Ophthalmology.

In an email to MedPage Today, co-author David Rein, PhD, MPA, of NORC at the University of Chicago, wrote, "We know this is driven primarily by the large increases in diabetes in the United States that have occurred over the last 20 years. The large number really underscores the importance of prioritizing eye care and diabetic retinopathy screening among people with diabetes."

Previous estimates published by the Eye Diseases Prevalence Research Group in 2004 -- which only included data on adults ages 40 and over -- showed that 40.3% of adults with diabetes had DR and 8.2% had VTDR, corresponding to 4.1 million and 899,000 adults, respectively.

The number of Americans diagnosed with diabetes has increased from 15.24 million in 2004 to 28.7 million as of June 2022, according to the CDC.

In the current study, the prevalence rate of DR was found to be higher among Black and Hispanic Americans versus white Americans (34.4% and 29.2% vs 24.4%, respectively), and this was also true for VTDR (8.7% and 7.1% vs 3.6%, respectively).

"I think, not surprisingly, we saw the highest standardized prevalence rates of diabetic retinopathy among the entire population in some of the poorest areas, particularly in Deep South counties of the Cotton Belt and the South Texas Plains," Rein said. "This suggests that negative social determinants of health, such as poverty, lack of healthcare access, and likely poor diet and exercise are resulting in higher rates of diabetes, poorer glucose control among people with diabetes, and greater rates of diabetes complications, like diabetic retinopathy among those with diabetes."

"However, we don't know the real reasons why rates of diabetic retinopathy vary by place," he added. "Physicians can help by promoting long-term glycemic control and referring their patients with diabetes for routine dilated eye examinations to ensure timely DR detection and treatment."

In an invited commentary, Xiangrong Kong, PhD, of the Johns Hopkins University School of Medicine in Baltimore, noted that the study has "multiple levels of public health relevance."

"Recent advances in artificial intelligence, retinal image processing, and telemedicine technologies provide a tool box for designing DR screening programs," she wrote. "Timely cost-effectiveness analyses of DR screening programs are the necessary next step to inform policy making on DR prevention in the U.S. Estimates of DR prevalence and absolute numbers of DR provide critical parameters required for a cost-effectiveness analysis."

Kong also pointed out that the prevalence estimates for younger Americans, particularly those under 25, showed a need for greater public health awareness of the ocular complications from diabetes. The varying prevalence rates among demographic and geographic subgroups can also better inform national and state resource allocation for ophthalmologic care.

For this study, Lundeen and colleagues used data from the 2005-2008 and 2017-March 2020 NHANES, as well as Medicare fee-for-service claims from 2018, IBM MarketScan commercial insurance claims from 2016, population-based studies of adult eye disease from 2001 to 2016, two studies of diabetes in youth from 2021 and 2023, and a previously published analysis of diabetes by county from 2012. They used population estimates from the U.S. Census Bureau stratified by age, sex, race, and county, and included relevant data from the CDC's Vision and Eye Health Surveillance System.

Of the people living with DR, 5.56 million were men and 4.04 million were women, while of those living with VTDR, 1.05 million were men and 780,000 were women.