Association between socioeconomic status and diabetic retinopathy in individuals with type 1 diabetes: a systematic review and meta-analysis.

Abstract

Despite improvements in screening and diabetes management, diabetic retinopathy (DR) remains a leading cause of vision loss in individuals with type 1 diabetes (T1D). Although clinical risk factors for DR are well established, the impact of socioeconomic status (SES) on DR risk remains poorly defined. The objective of this study was to estimate the association between SES and DR in people with T1D. We searched MEDLINE, Scopus, and Web of Science from inception to May 2025 for observational studies evaluating the association between SES and DR prevalence or incidence in individuals with T1D. Two reviewers independently performed study selection, data extraction, and risk of bias assessment using the ROBINS-E tool. Random-effects meta-analyses were conducted using the Sidik-Jonkman method. Subgroup analyses were performed by DR severity, SES measurement level, geographic region, and study design. Certainty was graded using the GRADE framework. Twenty-two studies including 69,446 individuals from 13 countries were included. Low SES was significantly associated with higher DR risk (OR = 1.44; 95% CI: 1.21-1.71; I² = 75%). The association was stronger for proliferative or vision-threatening DR (OR = 1.55; 95% CI: 1.19-2.04; I² = 49.3%). Subgroup analyses confirmed consistent associations across study designs, SES definitions, and regions. Sensitivity analyses and trim-and-fill adjustments yielded similar results. Socioeconomic disadvantage is a significant and clinically relevant risk factor for DR in individuals with T1D. The effect appears more pronounced for advanced stages. Integrating SES into DR risk stratification models and screening strategies may be essential to promote equity and reduce preventable vision loss. CRD420251034446.