E p i d e m i o I o g y / H e a 11 h S e r v i c e s / P s y c h o s o c i a I



The Prevalence of Diabetic Retinopathy and Associated Risk Factors Among Sioux Indians

M E T H O D S — All diabetic SHS participant members of the Cheyenne River Sioux Tribe and the Oglala Sioux Tribe were invited to take part in this study. The SI IS is a project funded by National Heart, Lung, and Blood Institute to study cardiovascular diseases and associated risk factors in the American Indian communities of North and South Dakota, Oklahoma, and Arizona. Prevalence rates for diabetes among SHS participants aged 45-75 years in North and South Dakota are 33% for men and 46% for women (5). All members of the participating tribes aged 45-74 years were invited to undergo a standardized physical examination and laboratory and diagnostic testing and to answer questionnaires regarding lifestyle and medical history (6,7). In North and South Dakota, 5 1 % of eligible women and 59% of eligible men participated in the study. There was no statistically significant difference in the self-reported prevalence of diabetes among the participants and randomly selected nonparticipants. SHS participants were diagnosed with diabetes by a glucose challenge test (75 g) with a 2-h postchallenge level > 2 0 0 mg/dl. Participants who were already told by a medical care provider that they had diabetes and were being treated with either insulin or oral hypoglycemic medications were considered to have diabetes and were not given a glucose challenge test. SHS participants who consented to participate in this study had a complete eye examination, testing visual acuity, intraocular pressure, and slit-lamp evaluation at local field clinics at their respective reservations. The pupils were dilated and fundus photographs were obtained of each eye with a Topcon nonmydriatic camera using 3 5-mm slide film. Both the macula and superior temporal retinal fields were photographed for each eye, yielding a total of four photos for each patient (two for each eye). The photos were evaluated and graded by a local consultant ophthalmologist (JJ-H.) trained in vitreoretinal diseases for diagnostic and treatment recommendations. All participants with retinopathy were informed through their respective clinics and offered


OBJECTIVE— To estimate the prevalence of and risk factors for diabetic retinopathy among Sioux Indians of South Dakota. RESEARCH DESIGN A N D METHODS— Strong Heart Study (SHS) participants with diabetes who are members of the Cheyenne River Sioux Tribe and the Oglala Sioux Tribe were invited to have ophthalmological examinations in 1991. A total of 417 people had eye examinations out of the 488 diabetic SHS participants of the two tribes (85% participation rate). Fundus photographs were obtained of each eye and graded for severity of retinopathy using the modified Airlie House Classification Scheme. Risk factors for retinopathy were determined from the SHS database. RESULTS — The prevalence of diabetic retinopathy among participants from these tribes was 45.3%. Risk factors associated with severity of retinopathy include mean fasting glucose level, HbAlc, systolic blood pressure, urinary albumin-to-creatinine ratio, renal dialysis, and duration of diabetes. CONCLUSIONS — The prevalence of diabetic retinopathy among diabetic Sioux Indians is similar to or higher than the prevalence in other diabetic Indian and non-Indian populations. Aggressive glycemic and blood pressure control is urgently needed to reduce this high rate, and annual eye examinations to detect and treat diabetic retinopathy should be emphasized.

iabetes is a major health concern among the Northern Plains Indians. Since the 1940s, the prevalence of NIDDM has progressively increased to epidemic proportions (1). The Aberdeen Area of the Indian Health Services (IHS) comprises 17 tribes located on 15 service units in North and South Dakota, Nebraska, and Iowa. Its age-adjusted prevalence rate for diagnosed diabetes of 105.4 per 1,000 is the second highest for all areas in the IHS and is 1.5 and 4.2 times higher than the overall IHS and U.S. rates, respectively (2). The Northern


Plains Indians, primarily the Sioux, have an age-adjusted prevalence rate of 92.4 per 1,000, which is 3.7 times the U.S. rate (3). Diabetes is the leading cause of new cases of blindness in people 20-74 years old in the U.S., with ~ 4 - 6 million people with diabetes having retinopathy (4). In this study, we estimate the prevalence of diabetic retinopathy among Sioux Indians participating in the Strong Heart Study (SHS). Additionally, risk factors are identified and compared with other diabetic Indian populations.

From the New York Medical College (D.M.B.), Valhalla, New York; the Aberdeen Area Indian Health Service (R.M.S., T.K.W, G.R.L.), Public Health Service Indian Hospital; the Office of Educational Research (J J.H.); and the Department of Ophthalmology, University of South Dakota School of Medicine, Rapid City, South Dakota. Address correspondence and reprint requests to Thomas K. Welty, MD, MPH, Aberdeen Area Indian Health Service, Department of Epidemiology, 3200 Canyon Rd., Rapid City, SD 57702. Received for publication 25 July 1996 and accepted in revised form 22 November 1996. dBP, diastolic blood pressure; IHS, Indian Health Services; NPR, nonproliferative retinopathy; PDR, proliferative diabetic retinopathy; sBP, systolic blood pressure; SHS, Strong Heart Study; UACR, urinary albumin-to-creatinine ratio.



01). hard exudates. Our appropriate treatment. alcohol history (drinks per day and drinks per week). We found age. and 124 mmHg for no retinopathy The UACR was 1.2 years for participants with PDR. P values of <0.3 2. (9-12) and U.6 53. Information on at least one eye was available for only 413 people. C O N C L U S I O N S — The prevalence of diabetic retinopathy among this group of diabetic Sioux Indians was 45.5 2. poor field definition.9% in participants with no retinopathy and NPR.1 6.2 n Fasting glucose (mg/ml) HbAlc (%) sBP (mmHg) UACR Duration of diabetes (years) 177 170 183 178 118 SD 7.05 were considered to be statistically significant.Diabetic retinopathy among Sioux Indians Table 1—Presence of diabetic retinopathy Percentage No retinopathy NPR PDR Total 226 166 21 413 54. sex. nonproliferative retinopathy (NPR. total and HDL cholesterol.4 NPR Mean 209. For renal dialysis analysis. Age was found not to be a risk factor.6 559.5 31.4% and found duration of diabetes. We identified similar risk factors. fasting glucose. history of heart attack.9 758 DIABETES CARE. Approximately 45. and fasting plasma glucose level to be significantly associated with the severity of retinopathy.8 116 7.1 1. HbA lc . The mean sBP in participants with PDR was 143 mmHg.6 7.1 100 the categorical variables of renal dialysis (yes or no) and level of retinopathy (no retinopathy. blood cholesterol.259. The mean HbA lc level. Fishers exact probability test was used to examine the relationship between Table 2—Factors associated with retinopathy (P < 0. retinal hemorrhage without microaneurysms. Significantly more participants with PDR were receiving renal dialysis than participants with no retinopathy or NPR (12 vs. Rates reported in studies of other U.S. West et al.7 40.2 and 5.3% in PDR vs. Photos deemed ungradable as either having no retinal detail. Five factors were identified as being associated with severity of retinopathy (P < 0.9 7. The protocol for this study was reviewed and approved by the Aberdeen Area and Indian Health Service institutional review boards and by the Cheyenne River Sioux Tribe and the Oglala Sioux Tribe. therefore. or poor photo quality from decreased clarity or media opacity were excluded from the study. it could be underestimated. NPR. duration of diabetes.135. The methods in defining the severity of retinopathy in the other Indian population studies did not use the modified Airlie House classification scheme. soft exudates. This may be due to the small sample size and/or characteristics of this population.3 years. The mean fasting glucose level was 201 and 210 mg/dl in participants with NPR and PDR. and 53. the no retinopathy and NPR categories were combined into one group.9 130. 7. HbA lc . MAY 1997 . Indian diabetic populations (13-15) are summarized in Table 3. dBP.7 1. renal dialysis.3%.2 5. urinary albumin-to-creatinine ratio (UACR).807 in participants with PDR. and duration of diabetes were significantly associated with the severity of retinopathy.807 14. exercise.3 142.7% and 8. using the modified Airlie House Classification Scheme (8).S. NPR. as compared with 14. sBP. intravascular microvascular abnormalities without microaneurysms. however.8 10.3 17. was 9. Analysis of variance with a modified least-squares comparison procedure was used to test the differences in the mean values of risk factors among participants with no retinopathy. or nondiabetic retinopathy. Our assessment of stroke was based on patient history and/or clinic charts. systolic blood pressure (sBP).7 123.0 20.3 PDR Mean 201 9.5 12.1% having NPR and PDR. history of stroke. 131 mmHg for NPR. Fasting blood glucose. We did not find history of stroke to be a significant factor. respectively. renal disease. prevalence studies in the Hispanic population of San Luis Valley using this classification scheme are comparable (12). PDR). Logistic regression was not used because missing information for some of the important variables resulted in equations with only about 100 cases. VOLUME 20.6 n 120 115 126 120 115 SD 77.9 8. and BMI were not significantly associated with retinopathy in this population. risk factors were similar to our findings among the Sioux Indians. respectively (Table 1). respectively This was significantly higher than 174 mg/dl in participants with no retinopathy. NUMBER 5. a measure of glycemic control over the past 2-3 months. Although the Pima prevalence rate was lower. duration of diabetes. history of stroke. stroke. The photos were further evaluated and graded by the University of Wisconsin-Madison School of Medicine Department of Ophthalmology. years of smoking.5 n 14 14 16 14 16 SD 79. proliferative diabetic retinopathy (PDR).001) No retinopathy Mean 173. All readable photos were graded as follows: no retinopathy. dialysis.3% (14).3% of the peoples eyes whose photos were evaluated had diabetic retinopathy. smoking and alcohol history. with 40. P = 0.1 2.1 for no retinopathy The average duration of diabetes in participants with NPR was 12. Factors shown to have a relationship to the degree of retinopathy were plasma glucose level and duration of diabetes. or microaneurysms only). and BMI. and PDR. physical activity. diastolic blood pressure (dBP). 560 for NPR. However. (13) reported a prevalence rate of diabetic retinopathy in Oklahoma Indians to be 24. Risk factors were evaluated by comparing the graded level of retinopathy with data from the SHS that included age. plasma triglyceride level. The prevalence of diabetic retinopathy in Pima Indians was reported to be 18% (15). Factors associated with a higher prevalence of retinopathy included sBP.001) (Table 2). RESULTS — A total of 417 people had eye examinations out of the 488 diabetic SHS participants of the two tribes (85% participation rate). and renal disease. 1%.8 2. triglyceride levels were not evaluated in our study Another study among Oklahoma Indians (Cheyenne-Arapaho) reported prevalence rates of diabetic retinopathy to be 49.

Gohdes D. Oopik AJ. Govt. Leonardson is currently with Mountain Plains Research. U.15. 1987: estimates from a national outpatient data base. Hazuda HP. 111. no. In conclusion. PhD. The Diabetes Control and Complications Trial Research Group showed that with use of color photographs alone. Owing to limited resources and equipment.3%. 1995 (NIH publ. l):244-247. Acknowledgments — The opinions expressed in this paper are ours and do not necessarily reflect the views of the Indian Health Service. 1986 2. D. The modified Airlie House classification defines seven standard stereo photographic fields in classifying retinopathy (8). Diabetes 38:1231-1237. Am J Epidemiol 132:1141-1155. MD. Dici/?r(t\s 29:501-508. Moss SE: The Wisconsin Epidemiologie Study of diabetic retinopathy. Rapid City. Howard WJ. Report VII: a modification of the Airlie House classification of diabetic retinopathy. Parsley TL: The prevalence and risk of diabetic retinopathy among Indians of Southwest Oklahoma.640 279 257 1. Howard BV: The Strong Heart Study: a study of cardiovascular disease in American Indians: design and methods. Cheyenne-Arapaho. MD. Welty TK. Herlihy is currently in private practice. Arch Ophthalmol 105:1344-1351. duration of diabetes. Hildebrandt W Marshall JA. 1976 The Diabetes Control and Complications Trial Research Group: Color photography vs. 1987 DIABETES CARE. Patterson JK. Welty T. Mayer EJ. OD. Freeman W. 1980 Newell SW Tolbert B. Barbara Howard. thereby preserving vision and preventing blindness. Savage PJ. 1989 Dorf A. while serving Indian patients. Printing Office.C.J. 1993 3. Miller M: Retinopathy in Pima Indians: relationships to glucose level. MAY 1997 759 . Klein B: Vision disorders in dia. Arch Ophthalmol 102:520-526. HbA lc . Prevalence and risk of diabetic retinopathy when age at diagnosis is less than 30 years. Klein R: Diabetic retinopathy in Mexican Americans and non-Hispanic whites. and renal disease as being significant risk factors. whose presence is missed by all who worked with him. Valway S. Klein R. we are also indebted to all of the health care providers and staff who planned and implemented the eye examinations in the Pine Ridge and Cheyenne River reservations. the estimated prevalence rate of diabetic retinopathy among the Sioux Indians is 45. 1993 4. Richard Fabsitz. and Joseph Hartford. Oopik AJ. Seminoles. In Diabetes in America. 1981 Haffner SM. Colorado) (12) San Antonio. 14 photographs for each patient were not feasible. and Joseph B. for their invaluable comments. South Dakota. protocol of two photographs for each eye and of the use of color photographs alone may underestimate the prevalence of retinopathy in this population. duration of diabetes. Howard BV Savage PJ. Montana. and J. 9.S. 11. Elisa Lee. Ballantine EJ. Klein BEK. Lee ET. Davis MD. Dicibetes 37:878-884. Fong D. G. By implementing aggressive glycemic and blood pressure control. Gohdes D: Prevalence of diagnosed diabetes among American Indi. Pugh JA. 1995 Diabetic Retinopathy Study Research Group. Mary Buurma. II. Diabetes 25:554-560. fluorescein angiography in the detection of diabetic retinopathy in the Diabetes Control and Complications Trial. DeMets DL: The Wisconsin Epidemiologie Study of Diabetic Retinopathy. Oopik AJ. Bennett PH. Moss SE. This paper is in honor of Ruggles Stahn. in a tragic plane crash in Minot. Richard Devereux. References 1. Cowan LD. Arch Ophthalmol 102:527-532. with fasting blood glucose. PhD.370 45 24 49 18 42 45 39 7. Invest Ophthalmol Vis Sci 21:210-226. Gohdes DM: Diabetes in American Indians: a growing problem. These results are reflective of the health needs of the Sioux Indian population. Fabsitz RR. Stober JA: A detailed study of risk factors for retinopathy and nephropathy in diabetes. NY. The University of Wisconsin School of Medicine 12.13. Cowan LD. Texas (9) South-central Wisconsin (NIDDM only) (11) Number studied Rate (%) 417 142 973 1. Savage PJ. Bennett J. Robbins DC. We would like to thank the participants of the study. Klein BEK. Kiowas. Kaufman S. Go O. South Dakota. Helgerson SD. 95-1468) 5.R. 1995 6. MPH. Welty TK: Diabetes mellitus and impaired glucose tolerance in three Ameri. Valway SE: Diabetes 14. 1994. The high prevalence of retinopathy also stresses the need for annual eye examinations in this population. van Hcuvcn WAJ. betes. and Nebraska. l):271-276. Am] Epidemiol 142:254-268. and age at examination in a population with a high prevalence of diabetes mellitus. Erdreich LJ. Berinstein is currently at The New York Eye and Ear Infirmary. New York. Le NA.. North Dakota. MD. sBP.. Lee ET. Bozeman. Such intervention will allow early diagnosis and treatment.Berinstein and Associates Table 3—Prevalence rates of diabetic retinopathy in NIDDM diabetic populations Population Sioux (South Dakota) Comanches. Yeh JL. Walsh. Stem MP. D. PAC. 10. Robbins DC. 1984 Hamman RF. ~ 2 0 % of patients with no retinopathy had evidence of retinopathy on fluorescein angiogram (16). Diabetes Care 9:609-613. Fabsitz R. 1984 Klein R. Diabetes Care 6 (Suppl. J Okla State Med Assoc 82:414-423. 1988 Klein R. and its complications among selected tribes in North Dakota. Welty TK: Coronary heart disease prevalence and its relation to risk factors in American Indians: The Strong Heart Study.16. Diabetes Care 18:599-610. 1989 West KW. He died February 18. VOLUME 20. Cowan LD. age at diagnosis of diabetes. 1990 Howard BY Lee ET. Baxter J: Prevalence and risk factors of diabetic retinopathy in non-Hispanic Whites and Hispanics with NIDDM: San Luis Valley Diabetes Study. Cucchiara AJ. Diabetes Care 16 (Suppl. Moo-Young GA. Prevalence and risk of diabetic retinopathy when age at diagnosis is 30 or more years. can Indian populations aged 45-74 years: The Strong Heart Study. the prevalence of diabetic retinopathy could be reduced. Yeh JL. Stahn RM. 2nd ed. NUMBER 5.M. Washington. Fabsitz RR. Creeks (Oklahoma) (13) Cheyenne-Arapaho (Oklahoma) (14) Pima (Arizona) Hispanic (San Luis Valley. 8. including the Black Hills Regional Eye Institute. ans and Alaska Natives. Department of Ophthalmology for grading the fundus photos.

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