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In optometric practice we are responsible for looking after the health of the eyes as well as the vision of our patients. The message that patients receive from a wide variety of sources is that a regular eye examination is the best way for them to look after their eyes. This is not only from an optical correction standpoint but also in terms of any pathology that might threaten their sight. This is an area that we excel at, with referrals regularly made for sight-saving procedures and treatments. Not only this, but we have multiple options available to help with various non-sight-threatening conditions such as drops, lid wipes, eye masks, blinking exercises and, in some practices, dietary supplements. Unfortunately, that’s where a lot of the advice or treatment ends.

So what about a patient who has a family history of age-related macular degeneration and is concerned about the risks for them? Most optometrists would feel comfortable talking about the dangers to eye health caused by smoking, but what about advising on diet and more general lifestyle advice? What about the patient who is overweight, smokes, doesn’t exercise and has a poor diet – what advice could be given, should be given, and how should this advice be best offered? Many patients will be aware that an eye examination can check not just the health of the eye but can also give indications of other issues such as high cholesterol and blood pressure. As eye care professionals, we owe it to our patients to stay up to date with the latest studies and be able to give sound, research-based advice on how they can best look after themselves.

Research shows that patients expect their GPs to be proactive and discuss lifestyle modification in relation to health.1 The same expectations may be applied to optical professionals; after all, GPs are neither nutritionists nor exercise professionals, yet they are expected to give sound advice in both of these areas.

Unfortunately, this is not a simple task. Separating fact from fiction is very difficult when looking at nutrition and exercise. Many experts in the field argue about the best methods to reduce obesity and improve health – who to listen to can be unclear and opinion driven. Many of the links between lifestyle and health have a significant number of influences and variables and so unambiguous and categorical advice from research is not readily available.

Fortunately, we can refer to some evidence from research and also to government guidelines when giving advice that is appropriate to our patients. With levels of diabetes on the rise and obesity at the highest level it has ever been in the UK 2 surely there has never been a better time to promote a healthy lifestyle.

When considering lifestyle modification we are usually thinking about smoking, exercise, obesity and nutrition. All of these areas have implications with eye disease.

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Smoking

Smoking has been shown to increase the incidence of age related macular degeneration by 3 to 6 fold, as well as increase the risk of cataract and uveitis.4,5,6 Most optometrists and opticians should now feel comfortable talking about smoking and associated risks with their patients. Though there is a wealth of research and information available, perhaps the public awareness of risks to the eye is not so clear. It has been reported that 76% of the US population think that there is no association between smoking and blindness. In stark contrast to this, 77% of Australians were aware of the link which could be due to the ‘smoking causes blindness’ campaign that started in 2006. 7 This awareness may be a huge motivational factor for someone to quit, especially considering the findings of a UK study that ranked sight loss higher than lung cancer and heart disease as an incentive for youths to stop smoking.8

Effective communication involves ensuring the patient is fully aware of the facts regarding the dangers smoking presents to eye health. Judgemental or dictatorial approaches (‘you must stop smoking’, ‘it is a filthy habit’) not only risk alienating the patient and discouraging further care, but might even have the opposite effect of a rebellious continuation of the habit. Far better approaches involve giving the patient all the information they need about both the dangers and also what help might be accessible, and then leave it for them to make up their own mind themselves. The patient needs to be a part of the decision-making process for cessation to be effective.

The NHS has free services available such as expert support and quit kits – all of which are available through the GP or the NHS website.

Know what help is available - smoking

Diet

Nutrition is a term covering a wide field that can often be confusing and daunting. Most of the discussion within the optical community has focused on the carotenoids lutein and zeaxanthin, as well as the results from the large-scale, age-related eye disease studies (usually described as AREDS I and AREDS 2). Unfortunately, even though there has been immense focus on isolating individual constituents that promote eye health and prevent disease, we still can’t be certain. What seems to be clear is that a diet rich in foods that are abundant in nutrients is good for our eyes. Epidemiological studies have shown a correlation between vitamins, minerals, omega-3/omega-6 and phytochemicals and a reduction in eye disease. What is important to note is that the majority of these studies did not use supplementation, but instead relied on nutrition from natural food sources. That is not to say that supplements don’t have a place, but improved nutrition through diet modification and enhancement has scientific backing that is hard to dispute. Practitioners can say with confidence that good nutrition should be promoted to every patient who wants to maintain or improve their eye health. Using government guidelines along with referenced printed material may be the best approach, especially considering some of the time constraints that are present in the testing room. There are also tailored nutrient supplements that have been specifically designed for the eyes. These can be very beneficial for patients that may struggle to get the recommended levels of compounds like lutein and zeaxanthin from their diet alone. It is also a great way for patients who don’t like fish to increase their intake of anti-inflammatory omega 3, which has been found to show benefits for conditions such as dry eye syndrome.9

Obesity

Obesity levels are higher than they have ever been, and this trend doesn’t look like going into reverse anytime soon. Along with obesity there is an increased risk of diabetes which can have devastating effects on the eye. It is reported that 80% of patients with diabetes for 15 years or more will be affected by some form of diabetic retinopathy,10 and the correlation with being overweight is dramatic –- 90% of all diabetics aged between 16-54 are overweight or obese.11 Clearly, it is not the responsibility of an eye care professional to tackle the growing obesity epidemic, but it is our responsibility to be aware of the effects on eye health. It is also likely that proactive advice in this often fraught area will be encouraged. Early intervention may have major long term benefits for health and also health resource management. Eye care professionals are meeting people periodically throughout their life and so provide a useful point of contact for good effective health advice. With more pressure being put on companies and the public from government schemes, such as the suggested sugar tax, it is more likely than ever that patients will seek advice regarding lifestyle and eye health. Practitioners must be prepared for this likely evolution in practice.

Registered diabetics have annual screening which puts us in contact with them frequently, offering an opportunity to give information and advice. Studies show that diabetic patients that control their blood sugar level adequately are far less likely to develop diabetic retinopathy, along with kidney and nerve diseases.12 Whilst they will have been told that controlling their blood sugar is vital by their doctor, they may not be aware of the effects that it has on their eyes. With vision ranked consistently in surveys as the most important sense, this may help motivate them to do better.

Advice regarding obesity needs a degree of experience and sensitivity if it is to be effective. Again, keeping the patient on board at all times is crucial, ensuring that any decision is made by them having been made aware of the facts in a non-judgemental manner. Furthermore, obesity has many co-morbidities and so specific advice is usually best given as part of a general health care programme, under guidance and in liaison with other healthcare professionals.

Know what help is available - weight loss

Exercise

Regular exercise has benefits to overall health, and that includes eye health. Many eye diseases are linked to another condition, such as diabetes and high blood pressure, so anything that can reduce their incidence will have a knock-on effect on eye health. Whilst it is unrealistic to expect opticians and optometrists to become personal trainers to their patients it is easy to have the tools needed to discuss recommended exercise levels and the link with eye disease. At this point studies are limited as to the direct correlation between conditions (such as AMD, glaucoma and dry eye syndrome or DES) and exercise. However, AMD and DES have an underlying inflammatory component and exercise has been shown to promote antioxidant and anti-inflammatory effects.13 Increased physical activity has also been shown to increase blood flow to the retina and lower intraocular pressure which is a risk factor for glaucoma.14 Exercise can help reduce the incidence of obesity and can improve overall health. So, whilst there is no clear link with specific eye conditions, it is likely that increased exercise has strong protective effects that are yet to be fully understood.

It is important to note that exercise does not need to be done in a gym with the newest machines and exercise programs. Small, incremental changes can have a big impact – such as using the stairs instead of escalators or parking further away from the supermarket – and these can easily be implemented into daily life. In order to stay within our expertise it is important to rely on the government guidelines that have been set out.

Know what help is available - exercise

Children and young people 5-18 years

  • All children and young people should engage in moderate to vigorous intensity physical activity for at least 60 minutes and up to several hours every day.

  • Vigorous intensity activities, including those that strengthen muscle and bone, should be incorporated at least three days a week.

  • All children and young people should minimise the amount of time spent being sedentary (sitting) for extended periods. Individual physical and mental capabilities should be considered when interpreting the guidelines.

Adults 19-64 years

  • Adults should aim to be active daily. Over a week, activity should add up to at least 150 minutes (2½ hours) of moderate intensity activity in bouts of 10 minutes or more – one way to approach this is to do 30 minutes on at least 5 days a week.

  • Alternatively, comparable benefits can be achieved through 75 minutes of vigorous intensity activity spread across the week or combinations of moderate and vigorous intensity activity.

  • Adults should also undertake physical activity to improve muscle strength on at least two days a week.

    All adults should minimise the amount of time spent being sedentary (sitting) for extended periods.

Older adults 65+

  • Older adults who participate in any amount of physical activity gain some health benefits, including maintenance of good physical and cognitive function. Some physical activity is better than none, and more physical activity provides greater health benefits.

  • Older adults should aim to be active daily. Over a week, activity should add up to at least 150 minutes (2½ hours) of moderate intensity activity in bouts of 10 minutes or more – one way to approach this is to do 30 minutes on at least 5 days a week.

  • For those who are already regularly active at moderate intensity, comparable benefits can be achieved through 75 minutes of vigorous intensity activity spread across the week or a combination of moderate and vigorous activity.

  • Older adults should also undertake physical activity to improve muscle strength on at least two days a week.

  • Older adults at risk of falls should incorporate physical activity to improve balance and co-ordination on at least two days a week.

  • All older adults should minimise the amount of time spent being sedentary (sitting) for extended periods.

  • Individual physical and mental capabilities should be considered when interpreting the guidelines. All information taken from www.gov.uk.website

Giving Advice

Having the knowledge to be able to hold a conversation with a patient about a healthy lifestyle is vital. A recent study found that doctors and nurses who knew about lifestyle guidelines and their effects on health were far more likely to give advice to patients, while those who thought that it had little benefit were least likely.15 While it is great to be able to give correct advice, care needs to be taken not to be too proactive and to avoid offending the patient. Whilst the link between obesity and disease is becoming quite clear, the approach for a discussion with a patient needs careful consideration. A recent study 16 looked at the way in which obesity was described and how well the term was received. The results show just how different each term can be viewed, and this will undoubtedly have an impact on the receptiveness of the patient to taking the advice on board (See Figure 1).

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For practitioners that do not know the guidelines or perhaps are unaware of some of the benefits to a healthy lifestyle for eye health the first step is definitely going to be gaining knowledge in this area. Again, it is important not to step outside of our expertise, so general guidelines – ideally government guidelines- and information of the effects specific to eye health – are all that is needed. Printed material is useful and widely available from a variety of sources, such as the RNIB. Optometrists that conduct diabetic screenings see their patients annuallyand this gives the opportunity to advise on nutrition, exercise and smoking - which has been shown to be effective. A recent meta-analysis of studies looking at lifestyle modification and metabolic syndrome found that those on the lifestyle modification intervention had reduced related abnormalities such as high blood sugar levels and triglycerides, both of which are related to a variety of conditions like diabetes.17 Being approachable and available with information may be the best approach at this point, with care being taken not to be ‘pushy’ with advice and to not offend. After all, many people will take their body weight and health to be very personal and many do not want to discuss the issue in their opticians. This fine line can only be found with diligence and good patient-centred care.

The Patient Decides

Patient-centred care puts the patient at the centre of the decision- making process which is critical with lifestyle modification. If the patient is not motivated to improve their health through diet, exercise or some other form of lifestyle modification then routine advice that is not individually tailored will be of little benefit. Whilst persuading a patient of the benefits of exercise may be useful it may also be off putting and quite clearly not what they attended their appointment for. Perhaps the best approach is to allow the patient to drive the amount of information that is given in regards to lifestyle. That way, a highly motivated person who is worried about the risks of macular degeneration and wants to do everything possible to reduce their chances can be given the tools needed to help. At the same time a patient who has no interest in changing their lifestyle won’t be offended by their optician /optometrist telling them about the risks of obesity. This situation is very delicate – information booklets on diet may still be the best approach for patients who wish not to discuss lifestyle during an eye examination.

The rates of lifestyle related conditions are likely to keep rising as we become more sedentary and eat less nutritious foods. The government has many schemes in place to try and tackle the situation, with the sugar tax likely to be the start of many more to come. Obesity alone is expected to have cost the NHS £27 billion in 2015, up from £4.2 billion in 2007. 18 Research continues to show how lifestyle and diet can improve ocular health, such as the recent study that found higher intakes of green, leafy vegetables was associated with a lower incidence of glaucoma.19

At the very least, it is part of our responsibility to keep up to date with the evidence in relation to eye health and be able to confidently answer any questions patients may have to enable them to help themselves. Having the knowledge and being able to discuss how patients can improve their diet, increasing the amount of exercise they do and reducing the amount they smoke could have huge repercussions.

Iain Johnson, a dispensing optician with a qualification in nutrition, practises in Manchester

References

1 Ulbricht, Sabina, et al. Smokers’ expectations toward the engagement of their general practitioner in discussing lifestyle behaviors. Journal of health communication 16.2 (2011): 135-147.

2 www.hscic.gov.uk/catalogue/PUB16988/obes-phys-acti-diet-eng-2015.pdf

3 Richards, T, Coulter A, and Wicks P. Time to deliver patient centred care. BMJ 350 (2015): h530.

4 Vingerling, Johannes R, et al. Age-related macular degeneration and smoking: the Rotterdam Study. Archives of ophthalmology 114.10 (1996): 1193-1196.

5 www.nytimes.com/1992/08/26/us/smoking-and-cataracts

6 www.allaboutvision.com/smoking/

7 Kennedy, R D, et al. Smoking cessation referrals in optometric practice: a Canadian pilot study. Optometry & Vision Science 88.6 (2011): 766-771.

8 Moradi, P, et al. Teenagers’ perceptions of blindness related to smoking: a novel message to a vulnerable group. British journal of ophthalmology 91.5 (2007): 605-607.

9 Liu, A, and Ji J. Omega-3 Essential Fatty Acids Therapy for Dry Eye Syndrome: A Meta-Analysis of Randomized Controlled Studies. Medical science monitor: international medical journal of experimental and clinical research 20 (2014): 1583.

10 Fong, D S, et al. Retinopathy in diabetes. Diabetes care 27.suppl 1 (2004): s84-s87.

11 www.gov.uk/government/uploads/system/uploads/attachment_data/file/338934/Adult_obesity_and_type_2_diabetes_.pdf

12 DCCT Research Group. Diabetes Control and Complications Trial (DCCT): Update. Diabetes Care 13.4 (1990): 427-433.

13 Ford, Earl S. Does exercise reduce inflammation? Physical activity and C-reactive protein among US adults. Epidemiology 13.5 (2002): 561-568.

14 www.aao.org/eye-health/tips-prevention/exercise-eyes-vision-4

15 Williams, K, et al. Health professionals’ provision of lifestyle advice in the oncology context in the United Kingdom. European journal of cancer care (2015).

16 Volger, Sheri, et al. Patients’ preferred terms for describing their excess weight: discussing obesity in clinical practice. Obesity 20.1 (2012): 147-150.

17 Yamaoka, K, and Tango T. Effects of lifestyle modification on metabolic syndrome: a systematic review and meta-analysis. BMC medicine 10.1 (2012): 138.

18 https://www.noo.org.uk/NOO_about_obesity/economics

19 Kang, Jae H., et al. "Association of Dietary Nitrate Intake With Primary Open-Angle Glaucoma: A Prospective Analysis From the Nurses’ Health Study and Health Professionals Follow-up Study." JAMA ophthalmology (2016): 1-11.