Ethnicity, Race, and Baseline
Retinopathy Correlates in the Veterans
Affairs Diabetes Trial
NICHOLAS EMANUELE, MD1
JEROME SACKS, PHD2
RONALD KLEIN, MD3
DOMENIC REDA, MD2
ROBERT ANDERSON, MD4
WILLIAM DUCKWORTH, MD5
CARLOS ABRAIRA, MD6
FOR THE VETERANS AFFAIRS DIABETES
OBJECTIVE — The Veterans Affairs Diabetes Trial (VADT) cohort is enriched with ?20%
Hispanics and 20% African Americans, affording a unique opportunity to study ethnic differ-
ences in retinopathy.
RESEARCH DESIGN AND METHODS — Cross-sectional analyses on the baseline
are grouped into four classes of increasing severity: none (10–14), minimal nonproliferative
diabetic retinopathy (NPDR) (15–39), moderate to severe NPDR (40–59), and proliferative
diabetic retinopathy (60?). These four groups have also been dichotomized to none or minimal
(10–39) and moderate to severe diabetic retinopathy (40?).
RESULTS — The prevalence of diabetic retinopathy scores ?40 was higher for Hispanics
(36%) and African Americans (29%) than for non-Hispanic whites (22%). The difference be-
tween Hispanics and non-Hispanic whites was significant (P ? 0.05). Similarly, the prevalence
of diabetic retinopathy scores ?40 was significantly higher in African Americans than in non-
Hispanic whites (P ? 0.05). These differences could not be accounted for by an imbalance in
traditional risk factors such as age, duration of diagnosed diabetes, HbA1c(A1C), and blood
pressure. Diabetic retinopathy severity scores were also significantly associated with increasing
years of disease duration, A1C, systolic and diastolic blood pressure, the degree of microalbu-
between retinopathy severity and the percentage of people who had strokes or cardiac revascu-
larization procedures. There was an inverse relationship between retinopathy severity and total
Diabetic retinopathy scores were not associated with age.
CONCLUSIONS — Inadditiontomanywell-knownassociationswithretinopathy,ahigher
frequency of severe diabetic retinopathy was found in the Hispanic and African-American pa-
tients at entry into the VADT that is not accounted for by traditional risk factors for diabetic
retinopathy, and these substantial ethnic dif-
ferences remain to be explained.
Diabetes Care 28:1954–1958, 2005
thy, and neuropathy in persons with type
crovascular complications are similarly
affected by blood glucose has not been
of the Veterans Affairs Diabetes Trial
(VADT) to determine the effect of excel-
lent glycemic control on macrovascular
risk in people with advanced diabetes in
whom treatment with oral hypoglycemic
agents and/or insulin already had failed.
In addition to macrovascular disease
at entry, patients in the VADT are evalu-
ated for microvascular complications in-
cluding retinopathy. Furthermore,
almost 20% of the cohort is Hispanic and
an additional 20% is African American.
Such a large and ethnically diverse group
of type 2 individuals affords a unique op-
portunity to study diabetic retinopathy in
various ethnic groups. Several reports
have addressed the question of whether
there is increased prevalence of retinopa-
thy in Hispanics and African Americans
inconsistent results (see CONCLUSIONS and
Table 5). With mydriatic seven-field ste-
reo fundus photographs taken on 1,283
individuals in VADT, important new data
are now available to address this issue.
Information on the baseline fundus pho-
tographs forms the basis of this report.
ntensive glycemic control has been
shown to decrease the onset and/or
progression of retinopathy, nephropa-
RESEARCH DESIGN AND
METHODS — The design of VADT
has been reported elsewhere (4). Patients
consented to a set of seven-field standard
stereoscopic color photographs of both
eyes, according to the Diabetes Retinopa-
thy Study protocol at baseline and at the
Reading Center of the University of Wis-
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
From the1Research Service, Hines Veterans Affairs Hospital, Hines, Illinois; the2Cooperative Studies
Wisconsin; the4Research Service, Omaha Veterans Affairs Medical Center, Omaha, Nebraska; the5Endo-
Service, Miami Veterans Affairs Medical Center, Miami, Florida.
Service (151), Room 2A103, 1201 NW 16th St., Miami, FL 33125-1693. E-mail: louisa.williams@med.
Received for publication 15 December 2004 and accepted in revised form 2 May 2005.
R.K. has been on an advisory panel for AstraZeneca. D.R. has received grant support from Novartis. R.A.
has received grant/research support from GlaxoSmithKline. W.D. has received honoraria or consulting fees
from Bristol-Myers Squibb, Novo Nordisk, and Aventis and has received grant/research support from Novo
Nordisk, Aventis, Roche, and Kos.
Abbreviations: NPDR, nonproliferative diabetic retinopathy; PAI, plasminogen activator inhibitor; PDR,
proliferative diabetic retinopathy; VADT, Veterans Affairs Diabetes Trial.
A table elsewhere in this issue shows conventional and Syste `me International (SI) units and conversion
factors for many substances.
© 2005 by the American Diabetes Association.
The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby
marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.
P a t h o p h y s i o l o g y / C o m p l i c a t i o n s
O R I G I N A LA R T I C L E
DIABETES CARE, VOLUME 28, NUMBER 8, AUGUST 2005