2. Prevalence of Diabetes in Adults (20-79 years), 2015
The world is facing an unprecedented epidemic of diabetes. The IDF estimates that in 2015, there are 415 million adults with diabetes worldwide, or 1 in 11 adults, which is a world prevalence of 8.8% of the world’s population who are living with diabetes.
North America and the Caribbean is the region with the highest prevalence rate of diabetes with 11.5% or 44 million people estimated to have diabetes. This is followed by the Middle East and North Africa region which has a prevalence rate of 10.7%, or 35 million people with diabetes. Next is the South East Asia region with 9.1% and 78 million people with diabetes. Western Pacific is the region with highest number of people living with diabetes (153 million), however its prevalence is 8.8%, the same as the prevalence of the World. South and Central America has 9.6% or 30 million people with diabetes. Europe has 58 million people or 7.3% with diabetes. Africa is the region with the lowest prevalence of diabetes at 3.8%, or 14 million people.
By 2040, it is projected that there will be 642 million people, or 1 in 10 adults, with diabetes. The biggest increase is projected to occur in the Middle East and Africa region, where it is expected that the number of people with diabetes will more than double from 35.4 million in 2015, to 72.1 million in 2040.
Reference:
IDF Atlas 7th Edition, 2015
415 million adults with diabetes worldwide, or 1 in 11 adults

3. 87-91% of cases are type 2 diabetes
35.8% of cases are undiagnosed in high-income countries, % in low / middle income countries.
87-91% of cases are type 2 diabetes
Type 2 diabetes factors: Lifestyle, culture, industrialisation, urbanisation, availability & affordability of processed foods, genetics.
Prevalence of diabetes is increasing globally, however, low and middle income countries shoulder the greatest burden of disease, where 75% of people with diabetes live % of adults with diabetes are undiagnosed and that number is higher is developing countries. Many low and middle income countries are experiencing an epidemiological transition that is characterised by a rapid increase in chronic disease such as diabetes, outnumbering prevalence of communicable diseases such as AIDS, malaria and tuberculosis. Health systems struggle to adapt as rapidly as the chronic disease burden grows. IDF estimates that in 2015, 5 million people died from causes associated with having diabetes. That is more than all the deaths from malaria, tuberculosis and HIV combined.
Type 2 diabetes accounts for over 90% of all cases of diabetes. The increase in type 2 diabetes in low and middle income countries is associated with changes in lifestyle, culture, industrialisation, urbanisation, an increase in the availability and affordability of processed foods, increasing obesity, physical inactivity and genetic factors associated with some indigenous populations.
Diabetes will increasingly impact those people living in economically developing countries as it imposes high human, social and economic costs. In future, the most significant growth in diabetes prevalence will occur in low and middle income countries. This poses a significant risk for the health systems and economies of these countries as they will carry the majority of the disease burden for treating diabetes and its complications. This has the potential to cripple health budgets and already overwhelmed health systems.
Diabetes is a major threat to global development, however, it has remained largely as a sleeper issue for public health and development, particularly in developing countries. This is why The Fred Hollows Foundation and the IDF have come together to tackle one of the serious complications of diabetes, diabetic retinopathy, with a focus of DR in low and middle income countries.
Reference:
IDF Atlas 7th Edition, 2015

4. As diabetes becomes more prevalent so do associated complications such as diabetic retinopathy. Diabetic retinopathy can cause irreversible vision loss. Of the 415 million people worldwide with diabetes in 2015, over one third will develop some form of diabetic retinopathy in their lifetime and a third of those will have impaired vision as a result. More than 93 million people currently suffer some sort of eye damage from diabetes. While advanced DR can lead to blindness, the early stages are entirely asymptomatic.
DR is currently the leading cause of vision loss in working-age adults. This has significant social and economic impacts for low and middle income countries as the impacts of blindness are greatest felt by the poor, their families and communities.
33% of those with diabetes will develop DR.
33% of those with DR will have impaired vision.
DR is the leading cause of vision loss in working-age adults.
This has significant impacts for low and middle income countries.
Reference:
IDF Atlas 7th Edition, 2015
IDF Atlas 6th Edition, 2013

5. Impacts of Vision Loss on the Poor
Less access to health support services
Loss of earning capacity
Loss of dependence and dignity
Need for greater social support
Women and girls suffer most
In low and middle income countries, poor health and health-related expenses can be a catalyst for lifelong impoverishment. When health care is needed but delayed or not obtained, it may result in worse health outcomes and increased health care costs. People in low and middle income countries face a greater threat from complications than those in wealthier countries as they do not have access to adequate health support services.
Blindness caused by diabetes can cause a devastating financial and social burden of eye disease on the poor, including a loss of earning capacity for those who become blind. As I previously mentioned, DR is currently the leading cause of vision loss in working-age adults, meaning people experience DR in the prime of their wage earning years. There are few government social services in low and middle income countries to support those unable to work due to blindness, therefore options of supplementing income are limited. This has flow on affects for the families of those who become blind as they are forced to survive on reduced income, whilst providing additional support to a blind family member.
And we all know that women and girls suffer the most from all the problems I just highlighted. They are the most vulnerable group taking the toll of all the hardships. It is true that you are more likely to be blind if you are uneducated or female. This is reflected in statistics on women and blindness globally. 60% of the worlds 32 million blind people are women. 90% of those blind women are living in poverty. Girls with visual impairment are less likely to attend school than boys and the burden of caring for a blind relative, as with most disabilities, almost inevitably falls on women…often young women who sacrifice schooling in order to provide that care.

6. Effects of Vision Loss on a Person
Psychological
well-being
Fear of total blindness, feeling isolated and helpless, depression
Daily necessities: preparing meals, shopping, recognizing faces
IMPACT OF VISION LOSS
Physical
well-being
Work &
social
Integration
More difficult to care for self, increased risk of injury due to falls
Not only blindness, but any degree of moderate to severe visual loss due to any cause, affects the quality of life of people in a multitude of ways; including their psychological and physical well-being, their work and social integration and independence.
Blindness robs people of their independence and dignity and increases the need for greater social support and often this is in countries and localities where few options for specialised support for people with blindness exist.
In addition, blindness is perceived as one of the most feared complications of diabetes.
Reference:
Mitchell J, Bradley C. Health Qual Life Outcomes 2006
Wysong A et al. Arch Ophthalmol 2009
Lost independence
Forced to rely on caregivers, guilt
Work: going to work, continued employment in current job
Mitchell J, Bradley C. Health Qual Life Outcomes Wysong A et al. Arch Ophthalmol 2009

7. Health Related Quality of Life
Complication
Mean
Mild stroke
0.70
Diabetic neuropathy
0.66
Angina
0.64
Diabetic nephropathy
Amputation
0.55
Diabetic retinopathy
0.53
Blindness
0.38
End-stage renal disease
0.35
Major stroke
0.31
A study in 2007 was designed to understand, how people with diabetes weigh the quality of life associated with complications and treatments. Interviews with a multiethnic sample of 701 adults with diabetes were conducted. A 0–1 utility score scale was used, where 0 represents death, and 1 represents life in perfect health. Participants were asked to quantify what they think their quality of life would be in a perfect health state, compared to a health state affected by different complications and treatments associated with diabetes. The lower the score (closer to ‘0’) respondents gave, represents the perception of a lower quality of life.
Patients were given a description of a hypothetical health state, for example, life with diabetic retinopathy, and asked to consider life in that state. Patients were asked to give their preference for 10 years in the health state of interest and a shorter period of time in perfect health. For example 6 years of life in perfect health = 10 years with an amputation, therefore the utility score was 0.6.
On average, patients rated the quality of life with complications, especially end-stage complications, as very low. For example, health states following a major stroke, 0.31 and end-stage renal disease, 0.35, were perceived as a low quality life as they received low scores towards 0. Following this was blindness, with a score of 0.38, making it the health state with the perceived third lowest quality of life of diabetes complications. Patients rated complications of angina, diabetic neuropathy, and mild kidney disease similarly, while ratings for diabetic retinopathy were equivalent to amputation ratings. This indicates that blindness and diabetic retinopathy have an enormous impact upon people’s perception of their quality of life, particularly blindness.
Reference: Huang S et al. Diabetes Care 2007,
0 = death, 1 = life in perfect health
Huang S et al. Diabetes Care 2007

8. The worldwide rise of diabetes, and its complications, means there is an increasing need for health professionals to consider the possibility of diabetic eye disease even before the symptoms begin to show.
diabetic retinopathy may be asymptomatic until an advanced stage and then it is often too late for effective treatment, therefore it is imperative to support people in managing their diabetes and to have regular eye examinations.
People with diabetes need to be supported to play an active role in managing their diabetes. By improving their blood glucose and blood pressure control a person with diabetes can slow down the progression of diabetic retinopathy.
Most people with diabetic retinopathy do not have to go blind, however for early detection and treatment to be successful, regular screening for diabetic retinopathy must be integrated into their diabetes care, where timely detection, management and referral of diabetic retinopathy are facilitated.

9. Diabetes Eye Health
Produced by The Fred Hollows Foundation and the International Diabetes Federation
Co-written by a working group of professionals from the diabetes and eye health sectors
A practical Guide for health professionals
The Fred Hollows Foundation in partnership with the International Diabetes Federation (IDF), has put together a publication called, Diabetes Eye Health: A Guide for Health Professionals.
The Guide is co-written by a working group of experts from the diabetes and eye health care sectors.
Diabetes Eye Health: A Guide for Health Professionals is the first document of its kind on diabetes eye health written for health practitioners at the front line of diabetes management. The purpose of the Guide is to highlight the rising prevalence of diabetic-related eye disease, particularly diabetic retinopathy, and outline the actions they can take to address it. By providing information about eye disease as a potential complication of diabetes, the Guide aims to encourage and facilitate early diagnosis and treatment of diabetic eye disease, in particular diabetic retinopathy, as well as to improve care for people with diabetes through encouraging integration and cooperation across the health system.
This is a ‘Guide’ rather than ‘clinical guidelines’, offering practical evidence based advice to health care professionals on how include eye health in their ongoing management of people with diabetes.

10. Builds on Existing Diabetic Retinopathy Guidelines
Existing DR Guidelines available for eye health professionals
Audience for the Guide are those at the frontline caring for people with diabetes
Guide highlights right time and right place for eye health interventions provided by a range of healthcare professionals
The primary audience for the Guide is the broad suite of health professionals and care givers who care for people with diabetes, including primary health practitioners, general practitioners, endocrinologists, ophthalmologists and other eye care practitioners, nurses, diabetes educators and first contact health providers. Different health professionals play an important role in managing diabetes, screening for eye conditions and supporting patients to manage their own health conditions. Management of diabetes and diabetic eye care requires integration across the health care system.
Eye care practitioners including ophthalmologists and optometrists, have a role in identifying eye disease and managing people with diabetic retinopathy. In addition, Health professionals at the point of diabetes care provide an important opportunity to help to identify diabetes-related eye disease. Many people with diabetes, and health professionals who care for them, are not aware of the critical need to undergo regular eye screening. These screening examinations should be done annually or at least every two years. Therefore these health professionals, in many instances primary health practitioners may have the best opportunity to identify those at risk and provide or facilitate regular screening. They can also initiate discussion of patient concerns, particularly a common fear of permanent loss of vision.
Low resource settings, such as developing countries, generally have more limited resources comparative to more developed countries. In particular, access to more specialised eye health expertise may be limited. Therefore it is important to consider how to make best use of these resources or alternatives. Even in developed countries, rural areas may be underserviced by specialists, therefore rethinking how different healthcare professionals can be utilised in areas with different resource settings is essential.

11. The following slides provide a broad overview of the Key Messages of the Guide

12. Timing of Eye Screening
Type 1 Diabetes
Type 2 Diabetes
Gestational Diabetes
Initial
Five years after diagnosis of diabetes
As soon as possible after diagnosis of diabetes
As soon as possible after diagnosis of diabetes
Ongoing
Every one to two years
If diabetes resolves after pregnancy, no further screening needed
It is important that all people with diabetes are routinely screened for diabetic retinopathy in order to prevent progression and development of diabetes-related loss of vision.
Regular eye examinations are the only way to determine the extent of diabetic retinopathy: the patient may not yet be experiencing any vision loss as the early stages of retinopathy are asymptomatic.
This table outlines the timings of when people with diabetes should have regular eye examinations. Essentially, people with Type 1 or Type 2 diabetes should have regular eye screenings every one to two years.
Duration of diabetes is a major risk factor associated with the development of diabetic retinopathy.

13. Eye Examination
Ideally all people with diabetes should have at least an initial comprehensive eye examination by an eye care professional
If this is not possible, then eye screening should be performed consisting of visual acuity test and retinal examination
Ideally screening methods should be identical in different resource settings and the same sequence should be followed in both low-resource and resource-rich settings. As a minimum, managing eye health in people with diabetes should include:
Medical history
Comprehensive eye examination which includes:
A visual acuity test
A retinal examination adequate for diabetic retinopathy classification which would generally involve each retina being closely inspected for signs of diabetic eye disease using one of the following methods (which is detailed on the next slide).
Screening and photo grading services, Indonesia. Photo: Dwi Ananta, HKI. CC BY-NC 2.0 CEHJ

14. Retinal Examination Non-mydriatic retinal photography
Binocular indirect ophthalmoscopy
Mydriatic retinal photography
Slit-lamp biomicroscopy
A photographer working with a mobile clinic team takes fundus images in a rural hospital. Photo: Cristóvão Matsinhe. CC BY-NC 2.0 CEHJ

15. Normal retina Diabetic retinopathy
Haemorrhages
Macula
Central
Retinal Vein
Abnormal growth of blood vessels
Fovea
Central
Retinal Artery
Optic
Disc
Aneurysm
Retinal
Arterioles
Hard
Exudates
“Cotton wool” spots
Retinal
Venules
Venous beading
These retinal photos show the differences between a normal retina, and a retina with severe non-proliferative diabetic retinopathy with severe diabetic macular edema.
Approximately one third of people with diabetes will have diabetic retinopathy and approximately one third of those will have a form of diabetic retinopathy that threatens their vision and requires treatment. These photos demonstrate that timely referral is crucial to ensure early intervention.
Not shown:
Microaneurysms, new blood vessels, intraretinal microvascular abnormalities, vitreous haemorrhage
Optic Disc
Macula
Hard
Exudates
Haemorrhages
“Cotton wool” spots
Normal retina
Severe non-proliferative diabetic retinopathy with severe diabetic macular edema
Source: Singapore Eye Research Institute

16. Grading of Diabetic Retinopathy (DR)
No apparent DR
No abnormalities
Mild non-proliferative DR
Microaneurysms only
Moderate non-proliferative DR
More than just microaneurysms, less than severe non-proliferative DR
No signs of proliferative DR
Severe non-proliferative DR
Any:
Intraretinal haemorrhages
Venous beading
Intra-retinal microvascular abnormalities
Proliferative DR
Intraretinal microvascular abnormalities
One or more:
Neovascularisation
Vitreous/pre-retinal haemorrhage
The stages of diabetic retinopathy are classified in this table using the International Classification of DR Scale.

17. Referral Criteria No problems detected = REGULAR SCREENING DR detected
The retinal examination will indicate the most appropriate course of management.
If no eye problems are detected then regular visual acuity testing and retinal examination are recommended. If necessary, additional ophthalmological investigations are recommended if there is uncertainty regarding the diagnosis or difficulty conducting an eye screening.
If diabetic retinopathy has been detected, referral to an ophthalmologist for timely treatment is required.
Examination of the eye. Mozambique. Photo: Riccardo Gangale/Sightsavers. CC BY-NC 2.0 CEHJ

18. Ophthalmic Assessment of Diabetic Eye Disease
Record of medical history
Assessment of visual acuity
Slit-lamp biomicroscopy
Measurement of intraocular pressure
Gonioscopy (in certain cases)
Fundus examination
Once the person with diabetes has been referred to a specialist, they should undergo a complete ophthalmic examination including:
A record of medical history
An assessment of visual acuity
Slit-lamp biomicroscopy
Measurement of intraocular pressures
A gonioscopy (when neovascularisation of the iris is seen or in eyes with glaucoma suspect)
A fundus examination to assess diabetic retinopathy and DME using: slit-lamp biomicroscopy with dilated pupils or mydriatic retinal photography or non-mydriatic retinal photography with dilated pupil
Additionally, fluorescein angiography can be used to investigate unexplained decreased vision, identify capillary leakage, and as a guide for treating DME but is not needed to diagnose diabetic retinopathy or DME. Optical coherence tomography (OCT) is the most sensitive method to identify the sites and severity of DME and to follow-up.

19. Treatment Options Laser photocoagulation Intravitreal anti VEGF
Intravitreal steroids
Vitrectomy
Timely treatment with laser photocoagulation and/or the use of anti VEGF treatments (intravitreal administration of vascular endothelial growth factor inhibitors) or steroid treatments can prevent vision loss, stabilise vision, and in some cases even improve vision if performed early, particularly for DME.
In more advanced cases of diabetic retinopathy like with associated vitreous haemorrhage and other , vitrectomy may need to be performed. This is a surgical procedure to remove the blood filled vitreous and/or tractions in the back of the eye. A vitrectomy is performed under either local or general anaesthesia by a specialist ophthalmologist.
Ophthalmic staff preparing to see patients, Ethiopia. Photo: Lance Bellers/Sight Savers. CC BY-NC 2.0 CEHJ

20. Post Treatment Support
Discuss clinical findings using patient’s own retinal images
Communicate eye exam results to other health professionals
Provide education and support on controlling blood glucose, blood pressure, and lipid levels
Following treatment there are several issues that need to be discussed with the person and their carers to ensure they understand the need for ongoing monitoring of their eye condition. These include:
Discuss clinical findings and implications, using a visual reference such as their own retinal images or photos. Use the images to reinforce the importance of both continued exams and of caring for their general health.
Communicate eye exam results to the other health professionals who are involved in the person’s care.
Continue to provide education and support on in controlling blood glucose, blood pressure, and lipid levels
Emphasise that treatment for diabetic eye disease is more effective with timely intervention and therefore the need for regular eye examinations
Refer for counselling, rehabilitation, or social services if available and appropriate.

21. Managing Diabetes Social support Nutritional support Medication
Medical examinations and treatment
Managing diabetes goes a long way to managing diabetic retinopathy. People whose diabetes is not well controlled are more likely to develop complications of the disease including retinopathy.
Diabetes management includes controlling blood pressure, blood glucose and lipid levels and this can be achieved by encouraging a healthy lifestyles and medication as required. Improved control can slow the progression of eye disease, especially when initiated soon after the diabetes is diagnosed.
Management of diabetes to reduce the risk of visual impairment, can be through four key strategies: social support, nutritional support, medication, and medical examinations and treatment—including a combination of all of these:
Social support
Peer-to-peer - Peer-to-peer group care sessions are found to improve health behaviour, quality of life and improve metabolic control.
Family support - Adding a family-based psychosocial support (where available), such as weekly meal planning, may help to improve diabetes management, especially for people with poorly controlled diabetes. Even among low-income households in low-resource settings, involving the family in meal planning can improve self-management of diabetes.
Healthy eating support
Good nutrition - Healthy eating and an improved understanding of the relationship between food and blood glucose levels can lead to improved metabolic control in people with diabetes.
Metabolic control - Overall improved glycaemic control can slow the progression of diabetic retinopathy, especially when initiated soon after the diagnosis of diabetes.
Medication
Medication such as anti-hypertensive and/or lipid-lowering drugs should be used to treat hypertension and dyslipidaemia, and when combined with lifestyle change, may slow the progression of diabetic retinopathy.
Medical examination and support
Early detection and regular check-ups - Diabetic retinopathy can permanently damage the retina and lead to blindness; however vision loss can be prevented by timely diagnosis of the early stages of non-proliferative diabetic retinopathy. Therefore regular eye examinations are essential
Timely treatment - Timely treatment can prevent vision loss and even stabilise and improve vision for many people. The decision to undergo treatment should be made jointly by both the person with diabetes and the health professional.

22. Managing Diabetes to Manage Eye Health
Communicate need for ongoing eye screening
Encourage lifestyle modification
Develop individual plans
Provide support for ongoing self-management
Ensure regular contact with health professionals
Ensure access to education programmes, including education on eye health
Strategies used by health professionals to support people with diabetes include:
Clearly communicate to the person with diabetes the need for ongoing eye screening over their lifetime
Encourage lifestyle modification; give individually tailored diabetes-specific advice about physical activity and nutrition
Develop individual plans that suit each person’s needs and are appropriate to resources available
Provide support for ongoing self-management
Ensure regular contact with health professionals and supportive peers
Ensure access to education programmes, including education on eye health.
Achieving and maintaining health-protective changes in behaviour can be difficult. There are many obstacles to living a healthy lifestyle, especially in low resource settings where it is often difficult to access healthy food, clean drinking water and affordable medications. Strategies which are found to be effective are socially and culturally appropriate structured interventions such as supportive group education sessions, increased physical activity, healthful dietary habits, and improved understanding of the relationship between food and blood glucose levels, which can enhance metabolic control.

23.
With the rapidly growing number of people developing diabetic retinopathy, the Guide is highly relevant for all health professionals caring for people with diabetes.
The Guide is available for download on the IDF website –
A Spanish language version of the Guide was launched January and is now also available on the same website.
Future versions of the Guide translated into French, Mandarin, Arabic and Russian will be released on the website in the coming months.

24. Supported by
Managing diabetes goes a long way to managing diabetic retinopathy. People whose diabetes is not well controlled are more likely to develop complications of the disease including retinopathy.
Diabetes management includes controlling blood pressure, blood glucose and lipid levels and this can be achieved by encouraging a healthy lifestyles and medication as required. Improved control can slow the progression of eye disease, especially when initiated soon after the diabetes is diagnosed.
Management of diabetes to reduce the risk of visual impairment, can be through four key strategies: social support, nutritional support, medication, and medical examinations and treatment—including a combination of all of these:
Social support
Peer-to-peer - Peer-to-peer group care sessions are found to improve health behaviour, quality of life and improve metabolic control.
Family support - Adding a family-based psychosocial support (where available), such as weekly meal planning, may help to improve diabetes management, especially for people with poorly controlled diabetes. Even among low-income households in low-resource settings, involving the family in meal planning can improve self-management of diabetes.
Healthy eating support
Good nutrition - Healthy eating and an improved understanding of the relationship between food and blood glucose levels can lead to improved metabolic control in people with diabetes.
Metabolic control - Overall improved glycaemic control can slow the progression of diabetic retinopathy, especially when initiated soon after the diagnosis of diabetes.
Medication
Medication such as anti-hypertensive and/or lipid-lowering drugs should be used to treat hypertension and dyslipidaemia, and when combined with lifestyle change, may slow the progression of diabetic retinopathy.
Medical examination and support
Early detection and regular check-ups - Diabetic retinopathy can permanently damage the retina and lead to blindness; however vision loss can be prevented by timely diagnosis of the early stages of non-proliferative diabetic retinopathy. Therefore regular eye examinations are essential
Timely treatment - Timely treatment can prevent vision loss and even stabilise and improve vision for many people. The decision to undergo treatment should be made jointly by both the person with diabetes and the health professional.
Supporters had no influence on the scope or the content of this publication