[Construction of evidence graph for modifiable risk factors for diabetic retinopathy]

Objective: Diabetic retinopathy (DR) has been reported as the leading cause of blindness among diabetic adults, which is closely related to poor quality of life and increased burden of disability. This study aimed to aggregate the optimally available evidence on modifiable risks of DR. Methods: Until June 2023, PubMed, Cochrane Library, CNKI, and Wanfang databases were used to retrieve Meta-analysis about various risk factors for DR, and Meta-analysis were analyzed and summarized. R 4.3.2 software was used for each Meta-analytic association to calculate the effect size, 95%CI, heterogeneity, small-study effects, excess significance bias, and 95% prediction intervals. The credibility of significant evidence was graded. Results: We captured 23 eligible papers (72 associations) covering a wide range of medication use, concomitant diseases, daily intervention, biomarkers, lifestyle, and physical measurement index. Among them, higher HbA1c variability (RR=1.45, 95%CI: 1.26-1.66) and urine microalbumin positive (OR=2.44, 95%CI: 1.99-2.97) were convincing (grade Ⅰ) evidence, and insulin use (RR=3.48, 95%CI: 2.14-5.67) was highly suggestive (grade Ⅱ) evidence. Moreover, hypertension (OR=2.03, 95%CI: 1.06-3.97), poor glycemic control (OR=4.35, 95%CI: 1.47-12.85), positive macroalbuminuria (OR=8.42, 95%CI: 3.52-20.15), long sleep duration (OR=2.05, 95%CI: 1.37-3.05), vitamin D deficiency (OR=2.02, 95%CI: 1.17-3.50), periodontitis (OR=4.51, 95%CI: 1.76-11.55) were the main risk factors for DR. Intensive blood pressure intervention (RR=0.78, 95%CI: 0.65-0.94), dietary control (OR=0.64, 95%CI: 0.47-0.89) and moderate intensity physical activity (RR=0.76, 95%CI: 0.59-0.97) yielded significant protective associations with DR. Conclusions: Intensive blood pressure glycemic control, and a healthy lifestyle pattern could reduce the risk of DR. This study provides the evidence to identify high-risk populations and recommends rational treatment options and healthy living interventions.