Mam Ibraheem, MD, MPH Epidemic Intelligence Service Officer Centers for Disease Control and Prevention 2012 CSTE Annual Conference June 5, 2012 Visual Impairment Among Adults Aged ≥40 Years — New Mexico, 2008 Office of Surveillance, Epidemiology, and Laboratory Services Scientific Education and Professional Development Program Office

Vision Loss : A Public Health Problem  Affects a lot of people  21 million have vision problems  80 million have potentially blinding diseases  Contributes large burden  Morbidity: depression, diabetes, hearing impairment, stroke, falls, cognitive decline, and premature death  Quality of life: inability to drive, read, keep accounts, and travel  Cost: estimated to exceed $51 billion

Vision Loss : A Public Health Problem  Recently increased and will increase in future  Rapidly aging U.S. population and increasing epidemics of diabetes  Blindness and visual impairment (VI) double by 2030  Perceived threat by public  Vision loss ranks among top ten causes of disability in United States  Feasible to act on at community or public health level  Early detection and treatment can prevent much blindness and vision impairment  Vision screening among adults aged ≥ 65 years: one of top 10 priorities among effective clinical preventive services

National Response  Healthy People 2010 : Chapter 28 Vision Objectives  National goal to "improve the visual and hearing health of the nation through prevention, early detection, treatment, and rehabilitation“  National Eye Institute: lead agency for vision objectives  10 vision objectives  CDC’s Vision Health Initiative (VHI)  Creates multilevel network for vision loss prevention and eye health promotion  Serves on the Healthy People 2020 Vision Work Group  May: Healthy Vision Month

Common Eye Disorders Among Adults Aged ≥40 Years Cataracts Glaucoma Diabetic Retinopathy Macular Degeneration

Vision Loss : At-Risk Populations  Hispanics and African Americans  Increased risk for glaucoma and diabetes complications  Unaddressed cataract  Older people at risk for age-related eye disease  Diabetics  Economically disadvantaged & socially isolated communities  Lack culturally relevant information and limited access to heath care  Rural communities lack education and limited health care access  Persons with modifiable risk factors?

Behavioral Risk Factor Surveillance System (BRFSS) Vision Surveillance  Optional “Visual Impairment and Access to Eye Care” module  First implemented in five states (Ohio, Texas, Louisiana, Iowa and Tennessee) in 2005  Individuals aged ≥40 years  9 questions assess prevalence of self-reported  Visual impairment  Eye disease  Eye examination  Implemented in NM in 2008  Access to eye care  Lack of eye care insurance

Study Objectives  Estimate overall visual impairment (VI) prevalence in NM  Estimate VI prevalence by race/ethnicity  Assess association between race/ethnicity and VI  Assess covariates and identify populations most at risk for vision loss to guide prevention strategies

Methods  2008 BRFSS data for 4,743 New Mexico adults aged ≥40 years  BRFSS: complex cross-sectional survey  Far vision: “How much difficulty, if any, do you have in recognizing a friend across the street?”  Near vision: “How much difficulty, if any, do you have reading print in newspaper, magazine, recipe, menu, or numbers on the telephone?”  While wearing glasses or contact lenses, for those who wore them

Main Outcome: Two VI Case Definitions No Difficulty A little difficulty Moderate difficulty Extreme difficulty Unable to do so because of eye sight 1. Broad: Any VI 2. Narrow: Moderate/Extreme VI Only Far or Near Vision Question

Main Exposure and Covariates  Main Exposure: race/ethnicity  Non-Hispanic white  Hispanic  American Indian or Alaska Native (AI/AN)  Other, non-Hispanic  Covariates  Demographics  Socioeconomic status  General health/comorbidity  Access to general health care or eye care  Lifestyle

Bivariate Analytic Methods  Survey-weighted percentages  P values associated with Pearson x 2  P value <0.05 statistically significant relationship  Data analyzed using STATA® 12

Overall White, non-Hispanic Hispanic AI/AN Broad (Any VI) Narrow (Moderate/Extreme VI Only)

Visual Impairment Prevalence by Demographics Characteristic Sample Size Any VIModerate/Extreme VI %95% CIP value%95% CIP value Total – –21.9 Race/Ethnicity White, non-Hispanic – –19.1 Hispanic – –29.4 AI/AN – –35.2 Sex Male – –21.4 Female – –23.5 Age groups (yrs) – – –23.2 ≥ – –20.6

Visual Impairment Prevalence by Demographics Characteristic Sample Size Any VIModerate/Extreme VI %95% CIP value%95% CIP value Total – –21.9 Race/Ethnicity White, non-Hispanic – –19.1 Hispanic – –29.4 AI/AN – –35.2 Sex Male – –21.4 Female – –23.5 Age groups (yrs) – – –23.2 ≥ – –20.6

Visual Impairment Prevalence by Demographics Characteristic Sample Size Any VIModerate/Extreme VI %95% CIP value%95% CIP value Total – –21.9 Race/Ethnicity White, non-Hispanic – –19.1 Hispanic – –29.4 AI/AN – –35.2 Sex Male – –21.4 Female – –23.5 Age groups (yrs) – – –23.2 ≥ – –20.6

VI Prevalence by Socioeconomic Characteristics Characteristic Sample Size Any VI Moderate/Extreme VI %95% CIP% P Employment status Employed – –19.6 Unemployed – –48.0 Education Level Less than high school – –39.2 High school graduate – –26.4 Attended college/technical school – –23.4 College/technical school graduate – –16.0 Annual Household Income <$15, – –43.2 $15,000–$24, – –28.1 $25,000–$34, – –28.1 $35,000–$49, – –25.8 ≥$50, – –15.9

VI Prevalence by Socioeconomic Characteristics Characteristic Sample Size Any VI Moderate/Extreme VI %95% CIP% P Employment status Employed – –19.6 Unemployed – –48.0 Education Level Less than high school – –39.2 High school graduate – –26.4 Attended college/technical school – –23.4 College/technical school graduate – –16.0 Annual Household Income <$15, – –43.2 $15,000–$24, – –28.1 $25,000–$34, – –28.1 $35,000–$49, – –25.8 ≥$50, – –15.9

VI Prevalence by Socioeconomic Characteristics Characteristic Sample Size Any VI Moderate/Extreme VI %95% CIP% P Employment status Employed – –19.6 Unemployed – –48.0 Education Level Less than high school – –39.2 High school graduate – –26.4 Attended college/technical school – –23.4 College/technical school graduate – –16.0 Annual Household Income <$15, – –43.2 $15,000–$24, – –28.1 $25,000–$34, – –28.1 $35,000–$49, – –25.8 ≥$50, – –15.9

VI Prevalence by Socioeconomic Characteristics Characteristic Sample Size Any VI Moderate/Extreme VI %95% CIP% P Employment status Employed – –19.6 Unemployed – –48.0 Education Level Less than high school – –39.2 High school graduate – –26.4 Attended college/technical school – –23.4 College/technical school graduate – –16.0 Annual Household Income <$15, – –43.2 $15,000–$24, – –28.1 $25,000–$34, – –28.1 $35,000–$49, – –25.8 ≥$50, – –15.9

VI Prevalence by General Health and Comorbidities Characteristic Sample Size Any VI Moderate/Extreme VI %95% CIP% P Adults with “good” or better health “Good” or better health – –18.1 “Fair” or “poor” health – –37.5 Ever diagnosed with a stroke Yes – –29.9 No – –21.2 Ever told by Dr. you have diabetes Yes – –47.0 No – –21.1

VI Prevalence by General Health and Comorbidities Characteristic Sample Size Any VI Moderate/Extreme VI %95% CIP% P Adults with “good” or better health “Good” or better health – –18.1 “Fair” or “poor” health – –37.5 Ever diagnosed with a stroke Yes – –29.9 No – –21.2 Ever told by Dr. you have diabetes Yes – –47.0 No – –21.1

VI Prevalence by General Health and Comorbidities Characteristic Sample Size Any VI Moderate/Extreme VI %95% CIP% P Adults with “good” or better health “Good” or better health – –18.1 “Fair” or “poor” health – –37.5 Ever diagnosed with a stroke Yes – –29.9 No – –21.2 Ever told by Dr. you have diabetes Yes – –47.0 No – –21.1

VI Prevalence by General Health and Comorbidities Characteristic Sample Size Any VI Moderate/Extreme VI %95% CIP% P Adults with “good” or better health “Good” or better health – –18.1 “Fair” or “poor” health – –37.5 Ever diagnosed with a stroke Yes – –29.9 No – –21.2 Ever told by Dr. you have diabetes Yes – –47.0 No – –21.1

VI Prevalence by Access to General Health or Eye Care Characteristic Sample Size Any VIModerate/Extreme VI %95% CIP% P Have any health care coverage Yes – –20.8 No – –33.0 Could not see Dr. because of cost Yes – –41.8 No – –19.2 Last time visited eye care provider <1m – –21.7 1m–<1yr – –19.9 1yr–<2yr – –22.4 ≥2yr or never – –31.9

Characteristic Sample Size Any VIModerate/Extreme VI %95% CIP% P Have any health care coverage Yes – –20.8 No – –33.0 Could not see Dr. because of cost Yes – –41.8 No – –19.2 Last time visited eye care provider <1m – –21.7 1m–<1yr – –19.9 1yr–<2yr – –22.4 ≥2yr or never – –31.9 VI Prevalence by Access to General Health or Eye Care

Characteristic Sample Size Any VIModerate/Extreme VI %95% CIP% P Have any health care coverage Yes – –20.8 No – –33.0 Could not see Dr. because of cost Yes – –41.8 No – –19.2 Last time visited eye care provider <1m – –21.7 1m–<1yr – –19.9 1yr–<2yr – –22.4 ≥2yr or never – –31.9 VI Prevalence by Access to General Health or Eye Care

Characteristic Sample Size Any VIModerate/Extreme VI %95% CIP% P Have any health care coverage Yes – –20.8 No – –33.0 Could not see Dr. because of cost Yes – –41.8 No – –19.2 Last time visited eye care provider <1m – –21.7 1m–<1yr – –19.9 1yr–<2yr – –22.4 ≥2yr or never – –31.9 VI Prevalence by Access to General Health or Eye Care

VI Prevalence by Lifestyle Characteristics Characteristic Sample Size Any VIModerate/Extreme VI %95% CIP%95% CI)P Physical activity in last 30 days Yes – –19.5 No – –31.4 Current smoking Yes – –30.0 No – –20.9 Heavy alcohol consumption Yes – –31.4 No – –22.0

VI Prevalence by Lifestyle Characteristics Characteristic Sample Size Any VIModerate/Extreme VI %95% CIP%95% CI)P Physical activity in last 30 days Yes – –19.5 No – –31.4 Current smoking Yes – –30.0 No – –20.9 Heavy alcohol consumption Yes – –31.4 No – –22.0

VI Prevalence by Lifestyle Characteristics Characteristic Sample Size Any VIModerate/Extreme VI %95% CIP%95% CI)P Physical activity in last 30 days Yes – –19.5 No – –31.4 Current smoking Yes – –30.0 No – –20.9 Heavy alcohol consumption Yes – –31.4 No – –22.0

VI Prevalence by Lifestyle Characteristics Characteristic Sample Size Any VIModerate/Extreme VI %95% CIP%95% CI)P Physical activity in last 30 days Yes – –19.5 No – –31.4 Current smoking Yes – –30.0 No – –20.9 Heavy alcohol consumption Yes – –31.4 No – –22.0

Summary Any VI was significantly more prevalent among:  Women  Age 40 –64 years  Unemployed  Less than high school graduate  Annual household income <$15,000  “Fair” or “Poor” health  Stroke  Diabetes  No health care coverage  Couldn’t see doctor because of cost  Last time visited eye care provider: never or ≥2 years  No physical activity in last 30 days

Multivariate Analytic Methods  Broad (Any VI) case definition only  Logistic regression model for complex-survey designs  Unadjusted and adjusted odds ratios  Data analyzed using STATA® 12

Odds Ratios for Any VI by Demographics Characteristic Unadjusted OR 95% CIP value Adjusted OR 95% CIP value Race/Ethnicity White, non-Hispanic11 Hispanic – – AI/AN – – Sex Male1 Female – – Age groups(yrs) 40– – – ≥6511

Odds Ratios for Any VI by Demographics Characteristic Unadjusted OR 95% CIP value Adjusted OR 95% CIP value Race/Ethnicity White, non-Hispanic11 Hispanic – – AI/AN – – Sex Male1 Female – – Age groups(yrs) 40– – – ≥6511

Odds Ratios for Any VI by Demographics Characteristic Unadjusted OR 95% CIP value Adjusted OR 95% CIP value Race/Ethnicity White, non-Hispanic11 Hispanic – – AI/AN – – Sex Male1 Female – – Age groups(yrs) 40– – – ≥6511

Odds Ratios for Any VI by Demographics Characteristic Unadjusted OR 95% CIP value Adjusted OR 95% CIP value Race/Ethnicity White, non-Hispanic11 Hispanic – – AI/AN – – Sex Male1 Female – – Age groups(yrs) 40– – – ≥6511

Odds Ratios for Any VI by Socioeconomic Characteristics Characteristic Unadjusted OR 95% CIP Adjusted OR 95% CIP Employment Status Employed11 Unemployed – – Education Level Did not graduate or graduated high school – – Attended or graduated college/technical school 11 Annual Household Income <$50, – – ≥$50,00011

Odds Ratios for Any VI by Socioeconomic Characteristics Characteristic Unadjusted OR 95% CIP Adjusted OR 95% CIP Employment Status Employed11 Unemployed – – Education Level Did not graduate or graduated high school – – Attended or graduated college/technical school 11 Annual Household Income <$50, – – ≥$50,00011

Odds Ratios for Any VI by Socioeconomic Characteristics Characteristic Unadjusted OR 95% CIP Adjusted OR 95% CIP Employment Status Employed11 Unemployed – – Education Level Did not graduate or graduated high school – – Attended or graduated college/technical school 11 Annual Household Income <$50, – – ≥$50,00011

Odds Ratios for Any VI by Socioeconomic Characteristics Characteristic Unadjusted OR 95% CIP Adjusted OR 95% CIP Employment Status Employed11 Unemployed – – Education Level Did not graduate or graduated high school – – Attended or graduated college/technical school 11 Annual Household Income <$50, – – ≥$50,00011

Odds Ratios for Any VI by General Health and Comorbidity Characteristic Unadjusted OR 95% CIP Adjusted OR 95% CIP Adults with “good” or better health “Good” or better health11 “Fair” or “poor” health – – Ever diagnosed with a stroke Yes – – No11

Odds Ratios for Any VI by General Health and Comorbidity Characteristic Unadjusted OR 95% CIP Adjusted OR 95% CIP Adults with “good” or better health “Good” or better health11 “Fair” or “poor” health – – Ever diagnosed with a stroke Yes – – No11

Odds Ratios for Any VI by General Health and Comorbidity Characteristic Unadjusted OR 95% CIP Adjusted OR 95% CIP Adults with “good” or better health “Good” or better health11 “Fair” or “poor” health – – Ever diagnosed with a stroke Yes – – No11

Odds Ratios for Any VI by Access to General Health and Eye Care Characteristics Characteristic Unadjusted OR 95% CIP Adjusted OR 95% CIP Could not see Dr. because of cost Yes – – No11 Last time visited eye care provider <2yr11 ≥2yr or never – –

Odds Ratios for Any VI by Access to General Health and Eye Care Characteristics Characteristic Unadjusted OR 95% CIP Adjusted OR 95% CIP Could not see Dr. because of cost Yes – – No11 Last time visited eye care provider <2yr11 ≥2yr or never – –

Odds Ratios for Any VI by Access to General Health and Eye Care Characteristics Characteristic Unadjusted OR 95% CIP Adjusted OR 95% CIP Could not see Dr. because of cost Yes – – No11 Last time visited eye care provider <2yr11 ≥2yr or never – –

Discussion  NM-specific estimates of self-reported prevalence of VI  VI prevalence substantially higher by using broad (any VI) than narrow (M/E VI Only) case definitions  Comparison to other states?

Significant Associations with Any VI  Middle age: Access to care/Medicare?  Stroke history, “fair” or “poor” health: Less likely to comply with annual eye appointments?  Lower socioeconomic status (unemployed, lower education, lower income): May be associated with less access to eye care or limited vision health literacy?  Limited care access: medical cost, regular visits to eye care provider?

Nonsignificant Associations with Any VI  Demographics: race/ethnicity, sex and lifestyle factors: smoking, drinking, exercise  Initial unadjusted associations confounded by other covariates  Inconsistent with past literature: were past studies properly controlling for confounding factors?  Comorbidity: Diabetes  Diabetic retinopathy is a leading cause of visual impairment  Outcome of interest in this study was VI from any cause

Study Limitations  Self-reported visual impairment  BRFSS data collection by landline telephone  Survey of civilian noninstitutionalized population  Cross-sectional survey  Not generalizable beyond NM population

Conclusions  VI prevalence varied substantially by different case definitions  VI prevalence highest among Hispanics and AI/ANs  Any VI in NM significantly associated with  Middle age  Stroke history  Limited care access  Lower socioeconomic status  Any VI in NM not significantly associated with race/ethnicity

Recommendations  Address New Mexico’s VI disparities through vision health initiative  Access to eye care services  Eye health literacy among groups at high risk  Continue surveillance of VI is important to better understand and plan for New Mexico’s vision care needs  Investigate eye care barriers to develop specific vision-loss prevention and eye-health promotion programs  Standardize case definition of vision loss in surveys and validate self-reporting methods

For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA Telephone, CDC-INFO ( )/TTY: Web: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Acknowledgments Office of Surveillance, Epidemiology, and Laboratory Services Scientific Education and Professional Development Program Office NM DOH: Michael Landen Wayne Honey Tierney Murphy Dan Green Mack Sewell CDC: Julie Magri John Crews Sheryl Lyss Jinan Saaddine Byron Robinson Betsy Cadwell

Conceptual Model for the Development of VI Baseline Absence of VI Sociodemograp hic Factors: Increased Age Male Gender Minorities (e.g. Hispanic Ethnicity) Decreased Acculturation Decreased Income Psychological Attributes: Decreased Social Support Depression Personal Health Practice Factors: Decreased Physical Activity No Knowledge of Eye Disease Decreased Intake of Antioxidant Supplements Biologic Risk Factors: Diabetes Complications: (Increased duration of diabetes, increased number of comorbidities, Increased blood pressure, increased BMI, HLA/genetic factors) Diabetes Severity/Control: (Increased HbA1c, increased blood glucose, increased insulin use) Increased Incidence/ Prevalence of VI Health Car Access and Utilization Factors: Decreased Health Care Coverage No Attitudes towards Health Care Decreased Utilization of Health/Eye Care Preventive Care Increased Barriers to Care

Common Eye Disorders  Infancy and Childhood (Birth to Age 18)  Amblyopia, Strabismus, and Refractive Errors  Adults Younger Than Age 40  Refractive Errors, Eye Injury, and Diabetic Retinopathy  Adults Older Than Age 40  Cataract, Diabetic Retinopathy, Glaucoma, Macular Degeneration Source: CDC’s Vision Health Initiative

Healthy People 2010 : Chapter 28 Vision Objectives  28-1: Increase the proportion of persons who have a dilated eye examination at appropriate intervals  28-2: Increase the proportion of preschool children aged 5 years and younger who receive vision screening  28-3: Reduce uncorrected visual impairment due to refractive errors  28-4: Reduce blindness and visual impairment in children and adolescents aged 17 years and younger  28-5: Reduce visual impairment due to diabetic retinopathy  28-6: Reduce visual impairment due to glaucoma  28-7: Reduce visual impairment due to cataract  28-8: Reduce occupational eye injury  28-9: Increase the use of appropriate personal protective eyewear in recreational activities and hazardous situations around the home  28-10: Increase vision rehabilitation

Economic Impact of Vision Loss in the United States — Total $51 Billion Source: CDC’s Vision Health Initiative

Vision Disability

BRFSS Vision/Eye Module  How much difficulty, if any, do you have in recognizing a friend across the street?  How much difficulty, if any, do you have reading print in newspaper, magazine, recipe, menu, or numbers on the telephone?  When was the last time you had your eyes examined by any doctor or eye care provider?  What is the main reason you have not visited an eye care professional in the past twelve months?  When was the last time you had an eye exam in which the pupils were dilated? This would have made you temporarily sensitive to bright light.  Do you have any kind of health insurance coverage for eye care?  Have you been told by an eye doctor or other health care professional that you NOW have cataracts?  Have you EVER been told by an eye doctor or other health care professional that you had glaucoma?  Have you EVER been told by an eye doctor or other health care professional that you had macular degeneration?