Fifth year medical student Phramongkutklao College of Medicine The Study of Prevalence and associated factors of Diabetic retinopathy in the Diabetic patients in Rural community, Central Thailand

Background Diabetes mellitus International Diabetes Federation. The IDF Diabetes Atlas, 2014

Diabetes mellitus in Thailand 6.3 million Diabetic retinopathy 13.6 – 31.4% Cataract Glaucoma Retinal detachment Visual impairment Blindness Chaicharn Deerochanawong. Diabetes management in Thailand; a literature review of the burden, costs, and outcomes International Diabetes Federation. The IDF Diabetes Atlas, 2014 Background

Initial dilated and comprehensive eye examination by an ophthalmologist or optometrist  Patients with type 1 diabetes : within 5 years after diabetes onset  Patients with type 2 diabetes : shortly after diagnosis  If no retinopathy for ≥1 eye exam : consider re-examinate every 2 years  If retinopathy : annual exam  Retinopathy progressing or sight threatening : more frequent exams 2015 American Diabetes Association (ADA) Diabetes Guidelines Background

Diabetic patients 67.7 % “Hospital - based” Community – based? An Assessment on Quality of Care among Patients Diagnosed with Type 2 Diabetes and Hypertension Visiting Hospitals of Ministry of Public Health and Bangkok Metropolitan Administration in Thailand, 2012 Background

Objective  To determine prevalence of Diabetic retinopathy among diabetic patients in Rural area, central Thailand  To determine associated factor of Diabetic retinopathy among diabetic patients in Rural area, central Thailand

Materials and Methods : Study method Quantitative study Cross-sectional study Prevalence Associated factor

Materials and Methods : Study method Individual factors Sex, Age Religion Marital status Education Occupation Early detection Biological factors Type of Diabetes Mellitus Duration of disease Diabetic status Underlying disease BMI Waist circumference Associated factorDiabetic retinopathy Research variable Serum creatinine Microalbuminuria Blood pressure HbA1C level

Materials and Methods : Study Population Quantitative study Inclusion criteria Diabetic patients in Takradan district, Sanam Chai Khet district, Chachoengsao Province Patients who are willing to join this research recruitment and had given consents Diabetic patients in rural community, Thailand Target population Studypopulation

Materials and Methods : Study Population Quantitative study Exclusion criteria Disability/ Death/ Moved Diabetic patients who were not able to give researched samples, i.e., blood and urine during certain time Studypopulation Target population Diabetic patients in rural community, Thailand

Materials and Methods Study procedure Diabetic patients Fundus photography Determine associated factor Determine prevalence Physical examination Investigation : Blood, Urine Questionnaire Statistic analysis Prevalence Associated factor Informed consent Descriptive Analytic

Tools and Data collection Demographic data Questionnaire Prevalence of DR Fundus photography Diagnosed by Ophthalmologists Associated factors Questionnaire Physical Examination, Lab investigation

 Reviewed and approved by the Institutional Review Board (IRB) of the Royal Thai Army Medical Department Ethical consideration

Result Table 1 : Demographic data of Diabetic patients N =172(%) Gender Male Female Age (years) < – – ≥ Mean ± SD(Min-Max)60.0 ± 12.0(21-97)

N =172(%) Status Married Widow/divorced/separated Single52.9 Education Non-literated Primary school Higher than primary school105.8 Occupation No occupation Farmer Other Result Table 1 : Demographic data of Diabetic patients

N =172(%) Income per month (Baht) No income < 5, ≥ 5, Scheme Universal health coverage Other179.9 Result Table 1 : Demographic data of Diabetic patients

N =172(%) Smoking Non-smoking Smoked Smoking2414 Alcohol Non-alcohol drinking Quit drinking Alcohol drinking3118 Result Table 1 : Demographic data of Diabetic patients

N =172(%) Duration of Diabetes (years) Median (Min-Max)6(0-30) On Diabetic treatment No Yes Metformin usage Not use Use Result Table 2 : Biological factors in Diabetic patients

Result N =172(%) Family history of Diabetic retinopathy No Yes95.6 Underlying of Kidney disease No Yes Underlying of Dyslipidemia No Yes Underlying of Hypertension No Yes Table 2 : Biological factors in Diabetic patients

Result N =172(%) Frequency of exercise per week < 3 days or no exercise ≥ 3 days BMI (kg/m 2 )* Underweight (<18.5)63.5 Normal weight (18.5 – 22.9) Overweight (23.0 – 24.9) Obese (≥25) Table 2 : Biological factors in Diabetic patients * WHO expert consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. The Lancet, 2004;

Result N =172(%) Waist Circumference (cm)* Male < 90, Female < Male ≥ 90, Female ≥ HbA1C (%) Well controlled (<7%) Poor controlled (≥7%) Table 2 : Biological factors in Diabetic patients * Misra A.Waist circumference cutoff points and action levels for Asian Indians for identification of abdominal obesity. Int J Obes (Lond) Jan;30(1):

Result N =172(%) GFR (min/mL/1.73 m 2 ) CKD stage I (GFR ≥ 90) CKD stage II (GFR 60 – 89) CKD stage III (GFR 30 – 59) CKD stage IV (GFR 15 – 29)148.1 CKD stage V (GFR < 15)52.9 Table 2 : Biological factors in Diabetic patients

Result Table 3 : Univariate and multivariate analysis for diabetic retinopathy DRNon DRCrude95%CIp-valueAdjusted95%CIp-value n(%) Odds ratio Gender Male 11(20.4)43(79.6) Female 18(16.4)92(83.6)11 Age (years) < 60 20(25.6)58(74.4) ≥ 60 9(10.5)77(89.5)11

Result Table 3 : Univariate and multivariate analysis for diabetic retinopathy DRNon DRCrude95%CIp-valueAdjusted95%CIp-value n(%) Odds ratio On diabetic medication No 2(6.7)28(93.3) Yes 27(20.1)107(79.9)11 Family history of diabetes retinopathy No 26(18.2)117(81.8)11 Yes 2(22.2)7(77.8) Underlying of kidney disease No 11(16.9)54(83.1)11 Yes 18(18.8)78(81.3)

 Total population was 245 people  Prevalence of Diabetic retinopathy among diabetic patient  37 diabetic patients has diabetic retinopathy (15.1 %)  Only 2 patients already got into the universal health coverage system Result

Compare result with previous study * Jongsareejit A. The Thai DMS Diabetes Complications (DD.Comp.) project; prevalence and risk factors of diabetic retinopathy in Thai patients with Type 2 Diabetic mellitus Hospital-based Studies * Community-based study Prevalence (%)13.6 – Associated FactorsDuration HbA1c High Blood pressure Age Underlying of kidney disease Chaicharn Deerochanawong. Diabetes management in Thailand; a literature review of the burden, costs, and outcomes. 2013

Discussion  Among 37 patients with diabetic retinopathy, only 2 patients already got into the universal health coverage system  Only 1 eye examination per year in this community  About 30 patients get their eye examinations per year

Discussion  Lack of ophthalmologist and fundus photography in rural communities  Underestimated prevalence due to unmovable fundus photography

Conclusion  Prevalence 15.1% (37 patients)  Only 2 patients got into the universal health coverage system due to inadequate health care supplies; ophthalmologist and fundus photography  Associated factors:  Age <60 years old  Underlying of kidney disease

Limitation  Unable to move fundus camera  Cataract had concealed fundus examination

Recommendation As there is only 1 eye examination for the community per year and it is rare to get an ophthalmologist to do an eye examination in such rural community, health care providers should encourage patients to control their disease and prevent them from getting severe complications.

Severe NPDR & PDR Require treatment Refer to Sanamchaikhet Hospital Mild & Moderate NPDR Encourage Diabetic control Arrange Follow-up DR screening Intervention

Acknowledgement 1. Department of Military and Community medicine, Phramongkutklao College of Medicine 2. Department of Ophthalmology, Phramongkutklao College of Medicine 3. Office of Research Development, Phramongkutklao College of Medicine

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