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The Kailuan Eye Study was a cross-sectional study conducted in 2016. The research followed the tenets of the Declaration of Helsinki. The Medical Ethics Committee of the Beijing Tongren Hospital approved the study protocol, and informed consent was obtained from every individual after explaining the nature and possible consequences of the study. The present study consisted of 14,440 individuals who had undergone an ophthalmologic examination, including ocular fundus photography. Body height and weight and the circumference of the waist and hip were measured and the body mass index (BMI) was calculated. The blood pressure and heart rate were assessed with the participants sitting for at least 5 min. Under fasting conditions, blood samples were collected to determine the concentrations of blood glucose, high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), triglycerides (TG), and total cholesterol (TC) levels.
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The diagnostic criterion for diabetes was a fasting blood glucose concentration of ≥ 7.0 mmol/L, a self-reported history of diabetes, or a history of medication with a hypoglycemic agent, including patients who no longer required medication to maintain good blood glucose control.
The diagnostic criterion for hypertension was a blood pressure ≥ 140/90 mmHg, a history of hypertension, or use of antihypertensive medications.
The basic components of the blood lipid profile include TC, TG, LDL-C, and HDL-C. The diagnostic criterion for hyperlipemia was based on the 2016 Chinese guidelines for the management of dyslipidemia in adults [28] (Tables 1 and 2).
Stratification TC LDL-C HDL-C Non-HDL-C TG Ideal level < 2.6 (100) < 3.4 (130) Appropriate level < 5.2 (200) < 3.4 (130) < 4.1 (160) < 1.7 (150) Marginal elevation ≥ 5.2 (200) and
< 6.2 (240)≥ 3.4 (130) and
< 4.1 (160)≥ 4.1 (160) and
< 4.9 (190)≥ 1.7 (150) and
< 2.3 (200)Elevation ≥ 6.2 (240) ≥ 4.1 (160) ≥ 4.9 (190) ≥ 2.3 (200) Reduction < 1.0 (40) Note. TC, total cholesterol; LDL-C, low density lipoprotein cholesterol; HDL-C, high density lipoprotein cholesterol; Non-HDL-C, non-high density lipoprotein cholesterol; TG, triglyceride. Table 1. Appropriate level and abnormal stratification standards of blood lipids in primary prevention of atherosclerotic cardiovascular disease (ASCVD) in China [mmol/L (mg/dL); 2016 edition]
Type TC TG HDL-C Equivalent to WHO phenotype Hypercholesterolemia Elevation IIa Hyperglycemia Elevation IV, I Mixed hyperlipidemia Elevation Elevation IIb, III, IV, V Low HDL-C Reduction Note. TC, total Cholesterol; TG, triglyceride; HDL-C, high density lipoprotein cholesterol. Table 2. Clinical classification of hyperlipidemia
The criteria for BMI was based on guidelines for prevention and control of overweight and obesity in Chinese adults, as follows[29]: underweight, BMI < 18.5 kg/m2; normal weight, BMI 18.5–23.9 kg/m2; overweight, BMI 24.0–27.9 kg/m2; and obesity, BMI ≥ 28.0 kg/m2.
The diagnostic criteria for AMD were based on the Beckman Macular Research Classification [30], as follows: no apparent aging changes (no drusen and no AMD pigmentary abnormalities), normal aging changes (only small drusen ≤ 63 μm and no AMD pigmentary abnormalities); early AMD (medium drusen > 63 μm and ≤ 125 μm and no AMD pigmentary abnormalities); intermediate AMD (large drusen > 125 μm and/or any AMD pigmentary abnormalities); and late AMD [neovascular AMD and/or any geographic atrophy (GA)].
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The ophthalmologic examinations included measurement of visual acuity, tonometry, and slit lamp-assisted biomicroscopy of the anterior segment of the eye. Using a non-mydriatic fundus camera (CR6-45NM; Canon, Tokyo, Japan), we obtained two 45° fundus photographs centered on the optic nerve head and on the macula. If fundus photographs with sufficient photographic quality could not be obtained due to the pupil diameter, we dilated the pupil medically by applying eye drops containing 0.5% tropicamide and 0.5% phenylephrine hydrochloride. The photographs were assessed by an experienced and trained ophthalmologist. Non-diagnostic photographs were reassessed by a panel comprised of several ophthalmologists.
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Statistical analyses were performed using a commercially available statistical software program (R software). The results are expressed as the mean and standard deviation or as the mean and 95% confidential interval (CI). Logistic regression models were used to estimate the odds ratios (ORs) and the 95% CIs of each risk factor for AMD. A P value < 0.05 was considered statistically significant.
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A total of 14,440 people were included in the Kailuan Eye study. According to the age definition standard of AMD, there were 9,627 people ≥ 50 years of age. Fifteen people with type 1 DM and 717 people with a questionable diagnosis of AMD were excluded. A questionable diagnosis of AMD was met if one of the following three criteria were met and the photograph was not clear: 1) unclear refractive media; 2) deviation of photograph range; and 3) lack of photographs. A total of 8,895 people entered the final statistical analysis (Figure 1).
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A total of 8,895 people ≥ 50 years of age were included in the Kailuan Eye study, 38 of whom had wet AMD. The prevalence of wet AMD was 0.4%. There were 1,469 patients with dry AMD, and the prevalence of dry AMD was 16.5%. Of the 1,469 patients with dry AMD, 1,034, 402, and 33 had dry AMD in the early, middle, and late stages, respectively. The prevalences of dry AMD in the early, middle, and late stages were 11.6%, 4.5%, and 0.4%, respectively.
There were 1,618 people > 50 years of age with type 2 DM in the Kailuan Eye study. There were 7,277 people without DM. The prevalence of type 2 DM was 18.2%. Among people > 50 years of age, five were diagnosed wet AMD and DM; the prevalence was 0.3%. Among people > 50 years of age without DM, 33 had wet AMD; the prevalence was 0.5%.
Among people > 50 years of age with DM in the Kailuan Eye study, 275 people had dry AMD; the prevalence was 17.0%. The number of people with early, middle, and late AMD was 184, 81, and 10, respectively; the prevalence was 11.4%, 5.0%, and 0.6%, respectively. Among the people without DM > 50 years of age, there were 1,194 people with dry AMD; the prevalence was 16.4%. The number of people with dry AMD in the early, middle, and late stages was 850, 321, and 23, respectively; the prevalence was 11.7%, 4.4%, and 0.3%, respectively (Table 3)[31].
Variables Wet AMD (%)* Dry AMD (%)** Dry AMD (n = 1,469) Early dry AMD (%) Mediate dry AMD (%) Late dry AMD (%) Non-DM
n = 7,27733 (0.5) 1,194 (16.4) 850 (11.7) 321 (4.4) 23 (0.3) DM
n = 1,6185 (0.3) 275 (17.0) 184 (11.4) 81 (5.0) 10 (0.6) Total
n = 8,89538 1,469 1,034 402 33 Note. *χ2 = 0.354, P = 0.551; when the level of significance was set at 0.05, there was no significant difference in the prevalence of wet macular degeneration between type 2 DM and healthy controls. **χ2 = 0.291, P = 0.590; when the level of significance was set at 0.05, there was no significant difference in the prevalence of type 2 DM and dry macular degeneration in healthy controls. AMD, age-related macular degeneration; DM, diabetes mellitus. Table 3. Prevalence of AMD in people with and without DM
Because the number of people with AMD was limited, if the patients with DM complicated by hypertension and hyperlipidemia were excluded, the prevalence of wet AMD was not counted. Therefore, to eliminate the confounding factors of DM combined with hypertension and/or hyperlipidemia, the healthy population (no diabetes, hypertension, or hyperlipidemia), hypertension-only population, hyperlipidemia-only population, and hypertensive combined with hyperlipidemia population were statistically analyzed for the prevalence of wet AMD and dry AMD, respectively. The prevalence of wet AMD was 5.0%, 3.0%, 2.0%, and 7.0% in the healthy, hypertension-only, hyperlipidemia-only, and hypertension combined with hyperlipidemia populations, and the prevalence of dry AMD was 16.6%, 16.2%, 15.2%, and 17.2%, respectively. The prevalence of early dry AMD in the hypertension-only, hyperlipidemia-only, and hypertension combined with hyperlipidemia healthy populations was 11.9%, 11.8%, 10.9%, and 12.0%, respectively, the prevalence of middle dry AMD was 4.4%, 4.2%, 3.9%, and 4.9%, respectively, and the prevalence of late dry AMD was 0.3%, 0.2%, 0.5%, and 0.3%, respectively. There were no significant differences in the prevalence of early, middle, and late dry AMD between the groups (Table 4).
Variables Wet AMD, n (%) Dry AMD, n (%) Dry AMD (n = 1,194) Early dry AMD, n (%) Middle dry AMD, n (%) Late dry AMD, n (%) Healthy
n = 3,23215 (0.5) 536 (16.6) 383 (11.9) 143 (4.4) 10 (0.3) Hypertension
n = 6192 (0.3) 100 (16.2) 73 (11.8) 26 (4.2) 1 (0.2) Hyperlipidemia
n = 1,5393 (0.2) 234 (15.2) 167 (10.9) 60 (3.9) 7 (0.5) Hypertension complicated
with Hyperlipidemia
n = 1,88713 (0.7) 324 (17.2) 227 (12.0) 92 (4.9) 5 (0.3) Total
n = 7,27733 1,194 850 321 23 Note. After inspection and comparison, when the significance level was set at 0.05, there was no significant difference in the prevalence of AMD among the groups. AMD, age-related macular degeneration; DM, diabetes mellitus. Table 4. Prevalence of AMD in non-DM individuals
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Because the number of people with wet AMD was limited and could not be statistically analyzed, only the risk factors for dry AMD were analyzed.
Three models were established to correct age and gender: corrected age, gender, and BMI; corrected age, gender, BMI, use of hypoglycemic drugs, and use of blood pressure-lowering drugs. The risk factors for dry AMD were analyzed, including DM, DM with hypertension, DM with hyperlipidemia, and DM with hypertension and hyperlipidemia.
DM, DM with hypertension, DM with hyperlipidemia, and DM with hypertension and hyperlipidemia were not risk factors for dry AMD (Table 5).
Variables Model 1, OR (95% CI)a Model 2, OR (95% CI)b Model 3, OR (95% CI)c Ref = non DM (n = 7,244) DM (n = 112) 1.08 (0.64, 1.73) 1.17 (0.69, 1.88) 1.18 (0.70, 1.91) DM with hypertension (n = 228) 1.01 (0.71, 1.42) 1.04 (0.72, 1.47) 1.07 (0.74, 1.52) DM with hyperlipidemia (n = 334) 1.00 (0.73, 1.34) 0.99 (0.72, 1.35) 1.02 (0.73, 1.39) DM with hypertension and hyperlipidemia (n = 939) 1.01 (0.84, 1.21) 1.02 (0.84, 1.24) 1.09 (0.88, 1.35) Note. aModel 1: corrected age (50−59, 60−69, and ≥ 70 years; sex (male, female). bModel 2: corrected for age, sex, and BMI (< 18.5, 18.5−23.9, 24−27.9, and ≥ 28.0 kg/m2). cModel 3: corrected for age, sex, BMI, use of hypoglycemic drugs (yes, no), and use of antihypertensive drugs (yes, no). AMD, age-related macular degeneration. Table 5. Risk factors for dry AMD (n = 8,857)
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The risk factors for dry AMD were analyzed by age stratification, with 10-year increments per age group. The OR for dry AMD was 1.56 (95% CI: 1.00–2.40) in the 60–69 year age group with DM and hyperlipidemia. None of the other age groups were risk factors for dry AMD (Table 6).
Variables Model 1, OR (95% CI)a Model 2, OR (95% CI)b Model 3, OR (95% CI)c 50–59 years Ref = non-DM (n = 3,185) DM (n = 51) 1.11 (0.45, 2.33) 1.21 (0.49, 2.55) 1.21 (0.49, 2.58) DM with hypertension (n = 88) 1.08 (0.55, 1.93) 1.14 (0.58, 2.05) 1.17 (0.59, 2.12) DM with hyperlipidemia (n = 171) 0.78 (0.45, 1.27) 0.74 (0.41, 1.25) 0.75 (0.41, 1.29) DM with hypertension and hyperlipidemia (n = 342) 1.24 (0.90, 1.69) 1.26 (0.89, 1.74) 1.36 (0.94, 1.93) 60–69 years Ref = non-DM (n = 3,079) DM (n = 49) 1.20 (0.58, 2.28) 1.25 (0.60, 2.41) 1.28 (0.61, 2.46) DM with hypertension (n = 106) 0.75 (0.42, 1.24) 0.77 (0.43, 1.30) 0.79 (0.44, 1.34) DM with hyperlipidemia (n = 130) 1.43 (0.93, 2.12) 1.51 (0.97, 2.28) 1.56 (1.00, 2.40) DM with hypertension and hyperlipidemia (n = 478) 0.87 (0.67, 1.12) 0.90 (0.68, 1.17) 0.94 (0.69, 1.28) ≥ 70 years Ref = non-DM (n = 980) DM (n = 12) 0.65 (0.10, 2.48) 0.80 (0.12, 3.32) 0.80 (0.12, 3.34) DM with hypertension (n = 34) 1.77 (0.84, 3.58) 1.57 (0.72, 3.27) 1.58 (0.72, 3.32) DM with hyperlipidemia (n = 33) 0.44 (0.13, 1.14) 0.40 (0.12, 1.07) 0.41 (0.12, 1.10) DM with hypertension and hyperlipidemia (n = 119) 1.06 (0.67, 1.64) 1.06 (0.65, 1.70) 1.10 (0.61, 1.91) Note. aModel 1: corrected gender. bModel 2: corrected gender and BMI. cModel 3: corrected for gender, BMI, use of hypoglycemic and antihypertensive drugs. AMD, Age-related Macular Degeneration; DM, Diabetes Mellitus. Table 6. Age subgroup analysis of dry AMD risk factors
The Influence of Diabetes, Hypertension, and Hyperlipidemia on the Onset of Age-Related Macular Degeneration in North China: The Kailuan Eye Study
doi: 10.3967/bes2022.081
- Received Date: 2022-04-12
- Accepted Date: 2022-06-26
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Key words:
- Diabetes /
- Hypertension /
- Hyperlipidemia /
- Age-related macular degeneration /
- Prevalence /
- Risk factor
Abstract:
Citation: | ZHANG Yong Peng, WANG Ya Xing, ZHOU Jin Qiong, WANG Qian, YAN Yan Ni, YANG Xuan, YANG Jing Yan, ZHOU Wen Jia, WANG Ping, SHEN Chang, YANG Ming, LUAN Ya Nan, WANG Jin Yuan, WU Shou Ling, CHEN Shuo Hua, WANG Hai Wei, FANG Li Jian, WAN Qian Qian, ZHU Jing Yuan, NIE Zi Han, CHEN Yu Ning, XIE Ying, JONAS JB, WEI Wen Bin. The Influence of Diabetes, Hypertension, and Hyperlipidemia on the Onset of Age-Related Macular Degeneration in North China: The Kailuan Eye Study[J]. Biomedical and Environmental Sciences, 2022, 35(7): 613-621. doi: 10.3967/bes2022.081 |