Gupta, P., Aravindhan, A., ATL, G., et al.
糖尿病 眼病 流行病学
摘要：重要性：糖尿病视网膜病变（DR）的存在和严重程度可能是导致糖尿病患者跌倒的危险因素，但目前尚无定论。目的：旨在探讨亚洲多民族人群中糖尿病与糖尿病视网膜病变严重程度与跌倒可能性之间的关联。设计，设置和研究对象：新加坡眼疾流行病学研究横断面事后分析，对2004年到2011年来自3个种族（3280名马来人，3400名印度人和3353名中国人）的研究对象进行基于人群的研究。这些受试者中，有552人缺少糖尿病，跌倒史或其他协变数据，或眼底照片不合格而被排除在外，共对9481名受试者进行了研究。这些受试者进行了标准化的临床检查，并回答了采访者问卷，收集了临床和社会人口信息。使用对混杂的跌倒风险因素进行调整的多变量逻辑回归模型评估了跌倒与糖尿病，DR和DR严重程度的相关性。对糖尿病患者进行趋势分析，以评估跌倒风险是否与DR严重程度相关。2017年1月1日至4月30日进行数据分析。暴露：糖尿病定义为随机葡萄糖水平200mg/dl以上，血红蛋白A1c浓度6.5以上，自我报告使用糖尿病药物，或医师诊断的糖尿病史。 DR的严重程度分为无，轻微，轻度，中度和视力威胁（VT）。主要预后指标：当研究对象发生跌倒时，前12个月自我报告的跌倒。结果：9481名研究对象平均年龄为58.7（10.3）岁（4781名女性[50.4％]），其中6612名（69.7％）无糖尿病，2869名（30.3％）患有糖尿病，其中857名（29.9％）至少有一只眼患有糖尿病DR。872例无糖尿病患者（13.2％），328例无DR患者（16.3％），44例最小DR患者（14.2％），54例轻度DR患者（26.2％），34例中度DR患者（27.2％） ，43例VTDR（19.9％）（P <0.0001）有跌倒史。在多变量模型中，与无糖尿病患者相比，DR患者更容易跌倒（[OR]，1.31; 95％CI，1.07-1.60; P = 0.008）。与没有糖尿病患者相比，无DR患者没有发现关联。此外，与糖尿病但无DR受试者相比，轻度（OR 1.81; 95％CI，1.23-2.67; P = .003）和中度（OR，1.89; 95％CI，1.16-3.07; P = .01）非增殖性DR更可能跌倒。结论和意义：与糖尿病但无DR患者相比，轻度至中度非增殖性DR的存在与糖尿病患者跌倒的可能性增加独立相关。糖尿病的治疗策略应包括防跌倒教育和预防知识，特别是早期DR患者。还需要纵向研究探索轻度至中度非增殖性DR与摔倒之间的关联来证实这些发现。
Importance:The presence and severity of diabetic retinopathy (DR) may contribute to the risk of falling in persons with diabetes, but evidence is currently equivocal.Objective:To investigate the associations of diabetes and DR severity with the likelihood of falls in a multiethnic Asian population.Design, Setting, and Participants:Cross-sectional post hoc analysis of the Singapore Epidemiology of Eye Diseases study, a population-based study of participants from 3 ethnic groups (3280 Malay, 3400 Indian, and 3353 Chinese individuals) conducted from 2004 to 2011. Of these participants, 552 had data missing on diabetes, falls history, or other covariates or had ungradable fundus photographs and were excluded, leaving 9481 participants. These 9481 underwent a standardized clinical examination and responded to an interviewer-administered questionnaire that collected clinical and sociodemographic information. Multivariable logistic regression models adjusted for confounding fall risk factors assessed the associations of falls with diabetes, DR, and DR severity. A trend analysis was conducted in participants with diabetes to assess if risk of falling was associated with DR severity. Data were analyzed from January 1 through April 30, 2017.Exposures:Diabetes was defined as a random glucose level of at least 200 mg/dL, hemoglobin A1c concentration of at least 6.5% of total hemoglobin, self-reported use of diabetic medication, or history of physician-diagnosed diabetes. Severity of DR was graded as none, minimal, mild, moderate, and vision threatening (VT).Main Outcomes and Measures:A self-reported fall occurring in the previous 12 months, when the participant fell and landed on the ground.Results:Of the 9481 participants with a mean (SD) age of 58.7 (10.3) years (4781 women [50.4%]), 6612 (69.7%) had no diabetes and 2869 (30.3%) had diabetes, of whom 857 (29.9%) had DR in at least 1 eye. A history of falls was reported in 872 (13.2%) without diabetes, 328 (16.3%) with no DR, 44 (14.2%) with minimal DR, 54 (26.2%) with mild DR, 34 (27.2%) with moderate DR, and 43 (19.9%) with VTDR (P for trend < .001). In multivariable models, those with DR were more likely to have fallen (odds ratio [OR], 1.31; 95% CI, 1.07-1.60; P = .008) compared with those with no diabetes; no associations were found for participants without DR compared with those with no diabetes. In addition, compared with participants with diabetes but without DR, those with mild (OR, 1.81; 95% CI, 1.23-2.67; P = .003) and moderate (OR, 1.89; 95% CI, 1.16-3.07; P = .01) nonproliferative DR were more likely to have fallen. Having VTDR was not independently associated with a higher likelihood of falling.Conclusions and Relevance:The presence of mild to moderate nonproliferative DR was independently associated with an increased likelihood of falling in persons with diabetes compared with persons with diabetes but without DR. Management strategies for diabetes should incorporate fall education and prevention information, particularly in patients with early-stage DR. Longitudinal studies exploring the association between mild to moderate nonproliferative DR and falling will be required to confirm these findings.