NATIONAL DIABETES AND DIABETIC RETINOPATHY SURVEY INDIA

2015-2019 – A SUMMARY REPORT

SURVEY CONDUCTED BY:

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi

National Programme for Control of Blindness &Visual Impairment,

Directorate General of Health Services,

Ministry of Health & Family Welfare, Government of India, New Delhi

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Key findings for National diabetes and diabetic retinopathy survey among

population aged ≥50 years

Indicators Percentage

Examined population (out of 63000 enumerated) 91.3

Prevalence of diabetes in surveyed population 11.8

Prevalence of known diabetes (KD) 8.0

Prevalence of new diabetes (ND)- Random blood sugar >200 mg/dl 3.8

Prevalence of diabetic retinopathy (DR) among diabetics 16.9

Prevalence of mild retinopathy 11.8

Prevalence of observable retinopathy 2.6

Prevalence of referable retinopathy 1.9

Prevalence of proliferative retinopathy 0.6

Prevalence of diabetic maculopathy 7.0

Prevalence of observable maculopathy 3.6

Prevalence of referable maculopathy 3.4

Prevalence of sight threatening DR 3.6

Introduction

The WHO estimated the global prevalence of diabetes among adults over 18 years of age as 8.5% in

2014. International Diabetes Federation report 2017 estimated there were 425 million diabetics in the

world and this figure is expected to increase to 629 million by year 2045. The increase is

disproportionately high in developing countries. There are estimated 72.96 million cases of diabetes in

adult population of India. The urban prevalence ranges between 10.9%-14.2% and rural prevalence

3.0%-7.8% among population aged 20 years above with a much higher prevalence among individuals

aged over 50 years (INDIAB Study). Diabetes and diabetic retinopathy have been emerging as a

significant non-communicable disease leading to ocular morbidity. It is estimated that diabetic

retinopathy was responsible for 1.06% of blindness and 1.16% of visual impairment globally in 2015.

There are no recent studies on the prevalence of diabetic retinopathy (DR) in different parts of India.

This makes it difficult to identify where DR screening and treatment programs are most needed. Most

available DR prevalence estimates are from diabetic clinics, which is subject to bias limiting their use

in planning ophthalmic services for diabetics in the general population. The present survey was

therefore planned to estimate the burden of diabetic retinopathy in the population aged ≥50 years for

assisting the planning and prioritization of diabetic eye services.

Aims and objectives

1. To assess prevalence of diabetic retinopathy and sight threatening diabetic retinopathy (STDR)

among people with diabetes.

2. To evaluate the coverage of diabetic retinopathy examinations among people with known diabetes

Methods

The survey was conducted using the Rapid Assessment of Avoidable Blindness + Diabetic Retinopathy

(RAAB+DR) survey methodology. Diabetes and DR assessment was carried out in 21 districts of India

selected using probability proportionate to size (PPS) systematic random sampling. A sample size of

3000 was targeted in each district by enrolling 60 individuals per cluster in 50 clusters. With 21 districts

included in the country, the total sample size for survey was 63,000 people aged 50 years and above.

The diagnosis of diabetes was made based on the participant having a history of diabetes, designated

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“Known Diabetes (KD)” or an elevated random capillary blood glucose (>=200 mg %) assigned as

New Diabetes (ND). Random capillary blood glucose (RBG) was assessed using a digital glucometer

by a trained laboratory technician. All the known diabetics and newly diagnosed diabetics aged 50

years and above were assessed for diabetic retinopathy by dilated fundus examination with indirect

ophthalmoscope by ophthalmologists. The Scottish DR grading system was used for classification of

retinopathy and maculopathy in each eye. Presence of laser scars was noted separately.

Results diabetes and diabetic retinopathy survey:

Prevalence of diabetes

Among 63,000 enumerated population aged ≥50 years in 21 districts, 56771 (90.1%) were assessed for

diabetes. The prevalence of diabetes was 11.8%. The prevalence of KD was 8.0% and ND was 3.8%.

Males showed a similar prevalence of diabetes (12%) as females (11.7%). Known diabetics comprised

67.3% participants, while 32.7% were new diabetics. Highest prevalence of diabetes was observed in

70-79 years age group at 13.2%. Nearly 40% of KDs were diagnosed 1-4 years back while 5.3% of

KDs reported diagnosis within past one-year.

Table 1: Prevalence of known and new diabetes among assessed in population aged ≥ 50 years

Diabetics Males Females Total

(n=24,210) (n= 32,561) (n= 56,771)

n % n % n %

Known diabetes 1979 8.2 2543 7.8 4522 8.0

Newly diagnosed diabetes 918 3.8 1277 3.9 2195 3.8

Total 2897 12.0 3820 11.7 6717 11.8

Figure 1: Proportion of known diabetes (KD) and newly diagnosed diabetes in population aged

≥ 50 years

67.3%

32.7%

Known diabetes Newly diagnosed diabetes

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Table 2: Age and sex wise prevalence of diabetes in population aged ≥ 50 years

Males Females Total

Age group

Years

Examined Diabetics % Examined Diabetics % Examined Diabetics %

50 – 59 9573 1008 10.5 14944 1615 10.8 24517 2623 10.7

60 - 69 8703 1139 13.1 10929 1428 13.1 19632 2567 13.1

70 - 79 4159 578 13.9 4545 567 12.5 8704 1145 13.2

≥80 1775 172 9.7 2143 210 9.8 3918 382 9.7

All ages

(Sample) 24210 2897 12.0 32561 3820 11.7 56771 6717 11.8

Figure 2: Duration of diabetes among known diabetics aged ≥ 50 years

Health seeking behavior for diabetes

Only 39.5% of known diabetics had RBG < 200 mg %. Most of these participants (85.7%) were on oral

tablets for diabetic management. Poor awareness regarding the health seeking for fundus eye

examination was evident as almost 90% of known diabetics had never gone for a fundus evaluation for

diabetic retinopathy.

Figure 3: Glycemic control (random capillary blood glucose < 200 mg %) among known

diabetics aged ≥ 50 years

5.3%

41.9%

26.7%

26.1%

<1 year 1 - 4 years 5 - 9 years 10 years or more

39.5%

60.5%

<200 (Good control) >=200 (Poor control)

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Figure 4: Treatment being taken by known diabetics aged ≥ 50 years

Figure 5: Last retina examination by known diabetics aged ≥ 50 years

Diabetic Retinopathy among Diabetics The prevalence of any form of diabetic retinopathy (DR) in diabetic population aged ≥ 50 years was

16.9%. Mild retinopathy (R1 grade) was the most common with prevalence of 11.8%. We observed

7% participants had any form of diabetic maculopathy. The prevalence of sight threatening diabetic

retinopathy was 3.6%.

The prevalence of DR was similar among males (17.0%) and females (16.7%). The prevalence of DR

in the 60-69 years age group was 18.6%, 70-79 years was 18.3% and >80 years was 18.4% while a

lower prevalence of 14.3% was observed in the 50-59 years age group.

5.9%2.9%

85.7%

5.6%

No treatment

Diet only

Tablets

Insulin with or without tables

89.9%

6.3%1.9% 1.9%

Not examined

0-12 months ago

13-24 month ago

>24 month ago

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Table 3: Prevalence of diabetic retinopathy, maculopathy and sight threatening diabetic

retinopathy in diabetic population aged ≥50 years (Scottish classification)

Total (N=5986) Prevalence

n (%)

Retinopathy

No visible retinopathy (R0) 4976 (83.1)

Mild (R1) 705 (11.8)

Observable background (R2) 155 (2.6)

Referable (R3) 113 (1.9)

Proliferative (R4) 37 (0.6)

Any retinopathy 1010 (16.9)

Maculopathy

No maculopathy (M0) 5569 (93.0)

Observable (M1) 215 (3.6)

Referable (M2) 202 (3.4)

Any Maculopathy 417 (7.0)

Laser Scars

No Laser Scars 5957 (99.5)

Pan retinal laser 23 (0.4)

Macular laser 1 (0.0)

Pan retinal and macular laser 5 (0.1)

Any Retinopathy and /or Maculopathy 1010 (16.9)

Sight Threatening DR (R4 or M2) 214 (3.6)

Figure 6: 1 Gender wise prevalence of any diabetic retinopathy (%) in diabetic population aged

≥50 years

17 16.7 16.9

0

5

10

15

20

25

Male Female Total

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Figure 7: Age wise prevalence of any diabetic retinopathy (%) in diabetic population aged ≥50

years

Figure 8: Prevalence of diabetic retinopathy and/or maculopathy (Scottish grading) (%) in

diabetic population aged ≥50 years

Prevalence of Blindness and visual impairment among diabetics

In our total diabetic population of 6717 persons, 144 persons were blind (PVA better eye <3/60) and

923 persons were visually impaired (PVA better eye < 6/18). Prevalence of blindness amongst diabetics

was 2.1% and visual impairment was 13.7%. Blindness and visual impairment were comparable in

diabetics and non-diabetics.

14.3

18.6 18.3 18.4

0

5

10

15

20

25

50-59 yrs 60-69 yrs 70-79 yrs ≥80 yrs

11.8

2.61.9

0.6

3.6 3.4 3.6

0

4

8

12

16

Mild(R1) Observablebackground(R2)

Referable(R3) Proliferative(R4) Observable (M1) Referable (M2) SightThreatening DR

(R4 or M2)

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Table 4: Prevalence of blindness and visual impairment in diabetic and total population

aged ≥ 50 years

Diabetics

(n=6717)

Non diabetics/

unknown status

(n=50,815)

Total Examined

(n=57532)

Blindness 144 (2.1%) 1035 (2.0) 1179 (2.0)

Visual impairment 923 (13.7%) 7128 (14.0) 8051(13.9)

District wise prevalence of diabetic retinopathy

The highest prevalenc of diabetes (over 20%) were observed in Thrissur, North Goa, Kapurthala and

Virudhunagar districts.

Figure 9: Prevalence of diabetes in surveyed districts (%)

Figure 10: Prevalence of any diabetic retinopathy (%) in diabetic population aged ≥50 years

9.4

22

8.3

4.1

8.7

7.4

4.8

9.1

8.7

24.7

7.2

5.3 6.3

10

.1 13

.2

5.7

13

18

.4

11

.6

21.2

29.4

11

.8

0

5

10

15

20

25

30

35

21.1

16.214.2

6.6

9.2

14.2

4.3

10.8

7.3

18.6

13.8 13.1

17.5 17.3 17.6

20.4

9

27.3

13.8

19.6

22.3

16.9

0

5

10

15

20

25

30

9

Figure 11: Prevalence of any diabetic maculopathy (%) in diabetic population aged ≥50 years

Figure 12: Prevalence of sight threatening diabetic retinopathy (%) in diabetic population aged

≥50 years

11.4

4.9

3.8

1.9

3.4

8.4

2.6

7

4.7

8

10.3

1.6

7.16

5.4

6.3

4.2

13.2

5.8

3.8

10.4

7

0

2

4

6

8

10

12

14

3.7

2.62.2

0

1

5.3

1.7

2.32.1

6.1

3.4

1.6

3.9

2

4.2

3.5

2.1

6.2

2.2 2.2

5.1

3.6

0

2

4

6

8

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NATIONAL INVESTIGATORS Prof. Atul Kumar, Chief, Dr. R.P. Centre, AIIMS, New Delhi

Prof. Praveen Vashist Officer In charge, Community Ophthalmology, Dr. R.P. Centre, AIIMS

Dr. Suraj Singh Senjam, Additional Professor, Community Ophthalmology, Dr. R.P. Centre, AIIMS

Dr. Vivek Gupta, Associate Professor, Community Ophthalmology, Dr. R.P. Centre, AIIMS

Dr. Noopur Gupta, Associate Professor, Ophthalmology, Dr. R.P. Centre, AIIMS

Dr. V. Rajshekhar, Assistant Commissioner, MOHFW, GOI

Dr. B.R Shamanna, Professor, University of Hyderabad, Telangana

DATA ANALYSIS AND REPORT WRITING

Prof. Praveen Vashist, Dr. Suraj Singh Senjam, Dr. Vivek Gupta, Dr. Noopur Gupta,

Dr. Meenakshi Wadhwani, Dr. Pallavi Shukla, Dr. Talvir Sidhu, Dr. Parul Jain,

Mr. Amit Bharadwaj, Mr. Sumit Sharma, Mr. Deepak Kumar, Mr. Rajesh Kumar Sharma

National Programme for Control of Blindness &Visual Impairment,

Directorate General of Health Services,

Ministry of Health & Family Welfare, Government of India, New Delhi

SURVEY CONDUCTED BY:

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi