Global, regional, and national burdens of blindness and vision loss attributable to diabetes from 1990 to 2021, and forecasts to 2045: analysis from the Global Burden of Disease Study 2021

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Global, regional, and national burdens of blindness and vision loss attributable to diabetes from 1990 to 2021, and forecasts to 2045: analysis from the Global Burden of Disease Study 2021

https://doi.org/10.21203/rs.3.rs-4886245/v1

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Background

Blindness and vision loss (BVL) is a major public health concern. Diabetes is associated with a series of vision loss causes. An understanding of the trend of the burden of BVL attributable to diabetes is critical for planning health policy.

Methods

We obtained global, regional, national, age- and sex-specific data on the prevalence and years lived with disability (YLDs) of BVL attributable to diabetes mellitus from the Global Burden of Disease Study 2021 (GBD 2021) and performed a secondary comparative analysis by time, location, SDI, age, gender and severity.

Results

From 1990 to 2021, the global incidence and age-standardized rate of BVL continuously increased. In 2021, 5836.5 thousand BVL cases attributable to diabetes occurred globally, and the age‐standardized rate for YLDs was 67.3 per 100,000 population. Great disparities were found across different genders, ages, and locations. Higher burdens appeared in females, elderly individuals, and regions with less advanced health systems.

Conclusions

The burden of BVLs attributable to diabetes has increased significantly since 1990 and varies widely across regions. Greater efforts are needed in diabetes control and vision protection, especially in elderly individuals and females, in regions with middle and low-middle SDI regions, and in regions with less advanced health systems.

Blindness and vision loss

diabetes mellitus

burden of disease

years lived with disability

With socioeconomic development and increasingly serious aging problems, blindness and vision loss (BVL) has become a global issue. In a previous report, in 2020, 43.3 million people suffered from blindness, 34.8 million people suffered from severe vision loss, 260 million people suffered from moderate vision loss, and 258 million people were affected by mild vision loss^[1]. BVL not only has negative effects on health and life expectancy but also influences individual social interaction, employment and socioeconomic inequalities^{[2, 3]}. Thus, visual health is a prevalent goal of different health organizations. To address this challenge, the World Health Organization (WHO) launched the “Vision 2020, Global Initiative for the Elimination of Avoidable Blindness the Right to Sight”. Despite these efforts, some progress has been made at some levels. However, BVL is still a leading public health issue.

The leading causes of BVL include cataracts, glaucoma, macular degeneration, diabetic retinopathy, trachoma, vitamin A deficiency, retinopathy of prematurity, meningitis, encephalitis, onchocerciasis, and a residual category of other vision loss. Remarkably, a large portion of BVLs are preventable.

Diabetes mellitus, recognized as a group of diseases characterized by signs and symptoms of chronic hyperglycemia, represents one of the largest epidemics globally in this century. In addition to chronic hyperglycemia and giant glycemic fluctuations, most of the burdens of diabetes mellitus are due to complications, commonly including cerebral stroke, coronary heart disease, renal dysfunction, peripheral neuropathy, retinopathy and blindness, all of which lead to disability and reduced life expectancy ^[4]. Diabetes-related BVLs are mostly preventable. Therefore, it is essentially important to explore the burden of BVL attributable to diabetes and draw more attention. However, reports on the burden of BVL attributable to diabetes at global, national, socioeconomic, sexual and age-specific levels are lacking.

To fill these gaps, this study aimed to comprehensively assess the burden of BVL attributable to diabetes mellitus by time, nation, age, gender, and socioeconomic status and to forecast this burden until 2045, with the aim of providing essential information for targeted health policies.

Study design and data sources

This study was a secondary analysis based on previously published data. Ethical approval was not applicable for this study. Data on the prevalence and YLD of blindness and vision loss were obtained from the Global Burden of Disease study 2021 (GBD 2021).

Case definition

All vision loss was estimated, and the severity was categorized as follows: (1) blindness, distance visual acuity of < 3/60 or < 10% visual field around central fixation; (2) severe vision loss, distance visual acuity ≥ 3/60 and < 6/60; (3) moderate vision loss, distance visual acuity ≥ 6/60 and < 6/18; and (4) near vision loss (uncorrected presbyopia), near visual acuity of < 6/12 distance equivalent. The direct causes of vision loss included uncorrected refractive error, cataracts, glaucoma, macular degeneration, diabetic retinopathy, trachoma, vitamin A deficiency, retinopathy of prematurity, meningitis, encephalitis, onchocerciasis, and a residual category of other vision loss.

YLDs were calculated with a microsimulation process that used estimated age-sex-location-year-specific prevalent counts of nonfatal disease sequelae (consequences of a disease or injury) for each cause and disability weights for each sequela as the inputs^[5]. The sociodemographic index (SDI) was applied as a composite indicator of social and economic conditions. It is the geometric mean of 0 to 1 indices of the fertility rate among females younger than 25 years, average years of education for those aged 15 years or older and lagged distributed income per capita^[5], ranging from 0 to 1.

Statistical analysis

The data are presented as values with 95% uncertainty intervals (UIs). The age-standardized rates of YLDs were expressed as the number per 100 000 population. The Kruskal-Wallis test was used with nonnormal distributions to evaluate the difference in age-standardized rates between males and females. The autoregressive integrated moving average (ARIMA) model, widely used in time series analysis ^{[6, 7]}, was applied to estimate the burden of vision loss attributable to diabetes from 2021 to 2045 (R system, version 4.2.2; detailed method in the Supplementary file 2). Most statistical analyses, except those specified above, were conducted via Prism software version 9.0 (GraphPad, San Diego, California). A P value less than 0.05 was considered statistically significant.

Global burden of BVL attributable to diabetes from 1990 to 2021

Globally, in 1990, the prevalence of BVL attributable to diabetes was 1927.9 (95% UI: 1498.4 - 2440.7) thousand, and the rate was 48.8 (95% UI: 38.8 - 61.7) per 100,000 population (Table 1). In 2021, the number of BVL cases attributable to diabetes was 5836.5 (95% UI: 4622.9 - 7298.8) thousand, and the rate was 67.3 (95% UI: 53.6 - 84.2) per 100,000 population, with an annual growth rate of 3.26% compared with that in 1990. The number of YLDs in 1990 was 144.7 (95% UI: 96.9 - 209.2) thousand, increasing to 472.7 (95% UI: 312.8 - 678.8) thousand, with an annual growth rate of 7.31% (Table 1). The age-standardized rate of YLDs in 1990 was 3.6 (95% UI: 2.4 - 5.2) per 100,000 population, and increased to 5.5 (95% UI: 3.6 - 7.8) in 2021, with an annual growth rate of 1.65%.

BVL can be divided into four levels according to severity: near vision loss (presbyopia), moderate vision loss, severe vision loss, and blindness. Perhaps since presbyopia is unrelated to diabetes, in the GBD 2021, BVL attributable to diabetes included only moderate vision loss, severe vision loss and blindness. The prevalence of BVL cases attributable to diabetes [moderate: 3868.4 (95% UI: 2845.1 - 5081.4) thousand; severe: 640.8 (95% UI: 448.4 - 860.7) thousand; blindness: 1327.3 (95% UI: 998.4 - 1737.4) thousand], age-standardized rate (per 100,000 population) [moderate: 44.6 (95% UI: 33.0 -58.5); severe: 7.4 (95% UI: 5.2 -10.0); blindness: 15.3 (95% UI: 11.5 -19.9)], and the percentage change in the age-standardized prevalence rate from 1990 to 2021 [moderate: 0.94%; severe: 0.39%; blindness: 3.26%] varied by severity level (Fig. 1A-B and Supplementary Table 1 in Additional file 1). In addition, the number of YLDs [moderate: 117.2 (95% UI: 63.6 - 198.2) thousand; severe: 114.4 (95% UI: 68.5 - 183.9) thousand; blindness: 241.0 (95% UI: 150.7 - 362.0) thousand], age-standardized rate (per 100,000 population) [moderate: 1.4%; severe: 1.3%; blindness: 2.8%], and the percentage change in the age-standardized prevalence rate from 1990 to 2021 [moderate: 0.95%; severe: 0.39%; blindness: 3.25%] also varied by severity (Supplementary Table 2 in Additional file 1).

Burden of BVL attributable to diabetes by country and territory

In 2021, as shown in Figure 2, among the 204 countries and territories, the top 3 largest number of BVLs occurred in China: 1373.5 thousand (95% UI: 1040.3-1779.2), India: 829.3 thousand (95% UI: 650.8-1018.0), and Brazil: 320.2 thousand (95% UI: 257.6-394.3). The 3 countries with the highest BVL rates were Mauritius: 237.0 (95% UI: 189.0-294.0), Libya: 213.5 (95% UI: 167.3-271.1), and Mexico: 211.6 (95% UI: 170.7-261.5). In contrast, the Central African Republic [7.5 (95% UI:5.4-10.1)], Nigeria [9.3 (95% UI: 6.7 - 9.3)] and Equatorial Guinea [9.8 (95% UI: 6.8-13.1)] had the lowest age-standardized rates (per 100,000 population).

For YLDs, the highest numbers were observed in India [91.6 thousand (95% UI: 60.6-134.2)], China [86.3 thousand (95% UI: 56.6-125.6)], and Brazil [30.6 thousand (95% UI: 20.4-44.3)]. Mauritius [27.5 (95% UI: 18.1-39.0)], Cuba [22.1 (95% UI: 13.9-33.9)], and Mexico [20.6(95% UI: 14.0-29.6)] had the highest age-standardized rates (per 100,000 population). The Central African Republic [0.35 (95% UI: 0.21-0.54)], Equatorial Guinea [0.45 (95% UI: 0.28-0.70)], and Democratic Republic of the Congo [0.46 (95% UI: 0.27-0.71)] had the lowest age-standardized rates (per 100,000 population).

Burden of BVL attributable to diabetes by SDI and health system grouping level

Figure 3 shows the number and age-standardized rate of incidence and YLDs of BVL attributable to diabetes by the SDI. There was an association between the SDI and both the prevalence rate and the YLD rate. First, as shown in Figure 4A, in all SDI subgroups, both the prevalence rate and YLD rate clearly increased over time from 1990 to 2021. However, from 1990 to 2021, the highest prevalence rates and YLD rates always appeared in middle SDI regions.

For different severity levels of BVL, there were some discrepancies. For moderate vision loss and blindness (Figure 4B, 4D), the highest rates of prevalence and YLDs both presented in middle SDI regions, and the lowest rates presented in high SDI regions. For severe vision loss (Figure 4C), the highest rates of prevalence and YLDs both presented in low-middle SDI regions, and the lowest rates presented in high-middle SDI regions.

In the 2021 GBD study, information on health system grouping levels by location was provided. Generally, the trend by health system grouping level was similar to that of the SDI: from 1990 to 2021, the burden of BVL increased in all levels of health system groups (Figure 4E), and the heaviest burden appeared in countries with basic health systems or low health systems (Figure 4F‒H).

Burden of BVL attributable to diabetes by age

With age, both the global numbers and the age-standardized rates of prevalence and YLD caused by diabetes gradually increased, peaking at the 65–69 years of age, and then gradually decreased in the elderly (Fig 1E-F). As the BVL burden also increased with time, to observe the growth rate in different age groups, the percent change in burden was calculated to represent the annual rate of growth. The annual rates of increase in prevalence and YLD both peaked at ages 60--64 years (Fig 1 G-H).

Burden of BVL attributable to diabetes by sex

As shown in Figure 1 C-F, the BVL prevalence and YLD in females were consistently greater than those in males. For the age-standardized rates of BVL cases and YLDs, the trends remained invariable from 1990 to 2021, in all age groups. Notably, with time and age, the difference between the two genders clearly became more dramatic.

Future prediction of the burden of BVL caused by diabetes

On the basis of the trend observed, the ARIMA model was applied to project the future trend to 2045. As shown in Figure 1C-D, in 2045, approximately 7509.8 (95% UI: 5435.9 - 8643.8) thousand female cases and 4132.3 (95% UI: 3390.4 - 5341.5) thousand male cases are estimated. The prevalence rate per 100 000 population will reach approximately 132.9 (95% UI: 110.0 - 156.8) in females and 71.9 (95% UI: 54.5 - 84.5) in males. The YLD rate will reach approximately 8.0 (95% UI: 5.4 - 11.5) in females and 5.8 (95% UI: 3.8 - 8.4) in males.

This study presented a time trend of the burden of BVL attributable to diabetes mellitus from 1990 to 2021 and its global distribution by age, gender, nation and socioeconomic level. Previous studies have confirmed the association between diabetes and BVL. Among the causes of BVL, diabetic retinopathy, a complication of diabetes, has the most direct connection with diabetes. In addition, accumulating evidence has indicated that glucose is associated with glaucoma ^{[8, 9]} and cataracts ^{[10, 11]}. Overall, the crude prevalence rate and YLD rate have increased over the past 30 years, which is consistent with the findings of previous studies^[1]. In 2021, the crude prevalence and number of YLDs of BVL attributable to diabetes reached 5836.5 thousand and 472.7 thousand, respectively. After adjusting for demographic structure, the age-standardized rates of prevalence and YLD still reached 67.3 and 5.5 per 100,000 population, respectively. The large numbers and high rates all indicate the predominant impact of diabetes mellitus on BVL. The burden is expected to continue to grow in the next 20 years, suggesting the need for constant attention to this vital area.

Although the disease burden has maintained a consistent upwards trend globally, differences in geographical distribution have also been observed. At the GBD regional level, Central Latin America bears the heaviest burden. At the national level, Mauritius, Cuba, Mexico and Libya, all near the equator, have the highest age-standardized burden rates. Many countries located near the equator are accompanied by poor economic levels and are susceptible to high ultraviolet radiation, which is a risk factor for BVL^[12]. A previous study also revealed an association between poor socioeconomic status and the burden of cataract-related blindness^[13]. These regions and countries with heavier burdens should be given priority in future healthcare policies, especially for strengthening ultraviolet radiation exposure protection.

In addition, we found that the burden was greater in countries with middle SDI or low-middle SDI. Similarly, a previous study revealed that the HFPG-attributable burden of BVL was significantly negatively related to the SDI, and the peak burden appeared at an SDI of approximately 0.6 (low - middle SDI) ^[14]. The possible reasons might include satisfactory health care systems in high-SDI countries and low positive diagnosis rates in relatively low-SDI countries. Thus, more attention should be given to regions with middle and lower SDI values.

Gender disparity in the burden was detected. However, in all age groups, the burden of both gendered increased from 1990 to 2021. However, females consistently bear a higher rate of burden, especially after 55 years of age. Previous studies also revealed similar patterns of gender disparity, including cataracts, age-related macular degeneration ^[15], diabetic retinopathy ^[16] and refractive error ^[17]. This phenomenon may be partially due to the longer life expectancy of females with an accompanying higher risk of age-related BVL^[18] and may be partially due to the unequal family status in some countries, especially those with low-SDIs ^[19]. Lower cataract surgical coverage and lower spectacle affordability for correction of presbyopia were observed in females than in males^[20], probably because women are more difficult to finance independently. Therefore, more attention should be given to women to reduce gender inequality.

In regard to age disparity, the peak burden appeared at ages 65–70. Notably, the prevalence of the main causes of BVL, such as cataracts, glaucoma, macular degeneration, diabetic retinopathy, and diabetes mellitus, are strongly associated with old age. With age or with the progression of diabetes, the incidence of diabetic complications, including diabetes-attributable BVL, increases. In addition, the total percentage change increased with age. However, remarkably, the peak percentage change appeared at ages over 95 years. This phenomenon was predominantly due to the significantly prolonged life expectancy.

This secondary analysis of GBD data systematically fills the gap regarding estimates of BVL attributable to diabetes at the global and national levels, by time, age, gender, SDI, etc. This analysis adopted standard methods with the newest updated data and made a future prediction according to the trends. However, several limitations should also be noted. First, there was a weakness in the GBD data source and methodology, mainly including the limited quality of the data and the insufficiency of population-based data in relatively poor regions. Second, different health information systems unavoidably create some information gaps. Third, this study focused only on diabetes-related BVL, as other risk factors, such as hypertension and high body mass index, may also play important roles.

In conclusion, this study revealed the global health burden of BVL attributable to diabetes from 1990 to 2021 by nation, gender, age, SDI and severity. With time, even until 2045, diabetes-related BVL will continue to be a public concern. Healthcare programs focused on vision should be more imperative, and more attention should be given to diabetes prevention and treatment. Hopefully, this study will be meaningful for policy making.

Ethics approval and consent to participate: Not applicable.

Consent for publication: Not applicable.

Availability of data and materials: The data were retrieved from the Global Health Data Exchange (http://ghdx.healthdata.org/gbd-results-tool).

Competing interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest.

Funding: This work was supported by grants from the Natural Science Foundation of Zhejiang Province (LQ24H070002).

Authors' contributions: LXY, XH and YFX conceptualized and designed the study; LXY and XH collected and interpreted the data; LXY, XH and YFX drafted the manuscript; LXY and XH contributed equally to this work.

Acknowledgements: This study was based on GBD data and methodologies. We appreciate the visionary global health leadership of the Institute for Health Metrics and Evaluation (IHME) and the contribution of all anonymous collaborators, without whom this report would not be possible.

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Table 1 is available in the Supplementary Files section.

No competing interests reported.

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Global, regional, and national burdens of blindness and vision loss attributable to diabetes from 1990 to 2021, and forecasts to 2045: analysis from the Global Burden of Disease Study 2021

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Methods

Study design and data sources

Case definition

Statistical analysis

Results

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Supplementary Files

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