Jeffrey R. Anshel
Public awareness about the overall dangers of obesity is at an all-time
high, with television shows such as The Biggest Loser and public
health initiatives such as First Lady Michelle Obamas Lets
Move! campaign bringing these issues to the forefront. However, despite
the general knowledge of obesitys effects on stroke, heart disease,
osteoarthritis and hypertension, it is still the rare patient who is aware of
obesitys impact on eye health.
As patients undertake the difficult business of tackling their 2012 New
Years resolutions, the optometrist can offer yet another component to
their incentive to lose weight. For patients who might have become desensitized
to the usual warnings, learning about a potential loss of vision might provide
just the jolt of motivation they need.
|This patient with proliferative diabetic retinopathy in the
left eye had a BMI of 34 kg/m2 and hemoglobin A1C of 12%. |
|This patient with grade 3 hypertensive retinopathy had a BMI of
35 kg/m2 and blood pressure of 170/115 mm Hg.
Images: Pelino CJ
We dont always know what will motivate a patient to lose
weight, Hal R. Bohlman, OD, FAAO, a practitioner at James H. Quillen VA
Medical Center in Mountain Home, Tenn., told Primary Care Optometry
News in an interview. Many of them arent worried about the
possibility of heart disease, diabetes or cancer. But when they realize their
vision may be at risk, some of them will make a decision to modify their diet
and/or fitness habits.
Concerned but clueless
Knowledge of the various connections between obesity and ocular health
is virtually absent from the public consciousness, according to Jeffrey R.
Anshel, OD, FAAO, a private practitioner in Carlsbad, Calif., founding director
of the Ocular Nutrition Society (ONS) and PCON Editorial Board member. Dr.
Anshel cited a survey conducted by the ONS of more than 1,000 baby boomers on
the subject of eye health. He said although the survey respondents ranked their
vision as being their most valuable sense and a top health priority, they knew
very little about any connection between nutrition and the eye.
|This patient with ischemic hemispheric retinal vein occlusion
had a BMI of 37 kg/m2, blood pressure of 158/98 mm Hg, no history of diabetes
and smoked a pack of cigarettes a day. |
|This patient with dry AMD had a BMI of 35 kg/m2.
They said they worried about loss of vision almost as much as
heart attack and cancer, he told PCON, but as far as knowledge
went, they were basically clueless.
Dr. Bohlman cited an editorial published in the March 2009 issue of
Archives of Ophthalmology, which emphasized the importance of patient
education regarding obesity and diabetic retinopathy.
In the editorial, Drs. Gardner and Gabbay state that
ophthalmologists could be more effective in the treatment of diabetic
retinopathy by emphasizing the systemic factors that affect the development and
progression of diabetic retinopathy, rather than new lasers or vitrectomy
techniques, he said. What they are saying is, we need to be
communicating these deadly habits that our patients have, and, in many cases,
our patients have the ability to improve their conditions and prognoses for
Dr. Anshel agreed that optometrists have the power to do patients a
significant service by educating them on eye health and obesity.
Patients are confused, and they are searching, he said.
Doctors need to have good answers.
Obesity is a term used to define an excess of body fat,
which is represented in terms of body mass index (BMI), according to Joseph J.
Pizzimenti, OD, FAAO, an associate professor at NOVA Southeastern University in
Fort Lauderdale, Fla.
According to the National Institutes of Health, BMI is a measure of body
fat based on height and weight that applies to men and women.
In adults, obesity is defined as a BMI of 30 kg/m2 or
higher, Dr. Pizzimenti said in an interview. It is reasonable to
call obesity a disease.
According to Carlo J. Pelino, OD, FAAO, assistant professor at the
Pennsylvania College of Optometry at Salus University in Philadelphia, a
distinction should be made between obesity and overweight.
Overweight is a little bit different. That number (BMI of 25
kg/m2 to 29.9 kg/m2 ) just means weighing too
much, Dr. Pelino told PCON. It could be from extra muscle, bone or
water, or it could be from too much fat. Whereas obesity pretty much means
there is too much body fat.
Dr. Anshel said obesity is linked to just about all of the
major ocular conditions.
Were finding out that most of the chronic diseases are based
on inflammation, and, in America, we have a pro-inflammatory diet, he
said. Theres close to 60 peer-reviewed studies that link obesity to
an increase in these conditions.
Obesity and cataracts
Dr. Pelino said although cataracts are among the many diseases that are
linked to obesity, the precise nature of this connection is not yet fully
Obesity has been found to be a risk factor in cataracts, but the
mechanism is unclear, he said. Of the different types of cataracts,
cortical cataracts and posterior subcapsular cataracts have been most
consistently associated with obesity.
This 25-year-old female with pseudotumor cerebri had a BMI of
38 kg/m2. She experienced a 78-pound weight gain in the last 8 months and was
having headaches and transient visual obscurations.
Dr. Pelino cited findings from the Barbados Eye Study, in which a higher
waist-hip ratio was associated with increased incidence of cortical cataracts
in African Americans. He said the Blue Mountain Eye Study yielded similar
This study, which looked at white Australians, suggested that a
person with a BMI of more than 30 kg/m2 had an increased risk of
both cortical and posterior subcapsular cataracts, he said. But
its not understood why.
Finally, Dr. Pelino referenced findings from the Age-Related Eye Disease
Study (AREDS), which found that a high BMI was associated with moderate
This correlation is all the more baffling for the fact that an inverse
relationship does not seem to exist between cataracts and weight loss.
There is no evidence that losing weight prevents cataracts,
he said. So if a person thinks they can stop cataracts by losing weight,
thats not necessarily true. It doesnt appear to work in the
Diabetic retinopathy and AMD
While the correlation between cataracts and obesity may still be
unclear, other conditions have a more measurable connection.
The reasons why losing weight can reduce risk are better
understood for some conditions than for others, Dr. Bohlman said.
He said diabetic retinopathy is one condition for which the connection
is relatively straightforward.
Many patients with diabetes can eliminate their need for
medications after losing weight and waist circumference, and may also even
eliminate the diagnosis of diabetes from their medical problem list, he
said. Obviously, if they no longer have diabetes, then they have
significantly decreased their risk of developing diabetic
While the relationship of obesity to age-related macular degeneration is
somewhat more complex, researchers have put forth credible theories, Dr.
Scientists have proposed that adipose tissue competitively absorbs
the same nutrients that are necessary for good macular health, he said.
As adipose tissue in the body decreases, this becomes less of a risk for
macular degeneration to develop, and less of a risk to progress once its
Glaucoma: contradictory findings
According to Dr. Pelino, studies have found a relationship between
obesity and high intraocular pressure. He cited the Beaver Dam Eye Study, which
reported a significantly positive association between elevated IOP and a BMI of
more than 30 kg/m2.
There is evidence of a relationship between obesity and increased
IOP, but not necessarily glaucoma, he said.
While obese patients are more likely to have high IOP, Dr. Bohlman said
a study by Gasser found that they were less likely to have glaucoma than those
with normal BMI. He noted that the type of tonometry used may make a
Other ocular conditions that have been linked to obesity include floppy
lid syndrome, pseudotumor cerebri, exophthalmos, thyroid eye disease and
nonarteritic anterior ischemic optic neuropathy.
Dr. Pelino said pseudotumor cerebri, in particular, is a condition that
can benefit significantly from a patient losing weight.
Losing weight is likely to help all of these conditions, but for
pseudotumor cerebri, weight gain is the main risk factor, so that will make a
big difference, he said. If a pseudotumor cerebri patient loses 5%
to 10% of their body weight, this is going to help the condition.
Some other ocular conditions, such as dry eye, have not been directly
linked to obesity, but are linked to a healthy diet, Dr. Anshel said.
Dry eye can be improved through a balance of omega-3 and omega-6
fatty acids, he said. By cutting back on junk food, a patient can
lower his or her omega-6 intake and help achieve that balance.
The patient conversation
The first step in overcoming ocular conditions through weight loss is to
introduce the topic to the patient. This conversation can be not only
uncomfortable to the patient, but often a total surprise in an eye care
Most patients I talk to are surprised that their eye doctor is
talking to them about obesity, Dr. Bohlman said. Most have never
heard of the ocular complications of their obesity.
Dr. Pelino emphasized that the topic of obesity is often a sensitive
one, and he tries to broach the subject in a nonconfrontational way. He said he
begins by asking the patient if they know what BMI is and, if not, he explains
it. At this point, rather than telling the patient he or she is obese, he lets
the numbers tell the story.
We have computers in our exam rooms with BMI calculators on them,
so I ask patients if I can calculate their BMI for them, he said.
They will see right away what their number is and whether they are
technically overweight or technically obese.
Dr. Anshel said he offers patients the Eye on Nutrition
brochure from the ONS, which explains some of the connections between diet and
I tell them, Here is a brochure that talks about how
nutrition affects your eyes and, last time I checked, the eyes are a part of
the body. So I keep it light, but I keep it professional.
Dr. Bohlman said in discussing obesity with patients, he aims to avoid
sounding like yet another scolding voice.
I want patients to understand that the reason I am bringing this
subject up is that I am truly concerned with their health and well-being,
he said. I want to avoid having them think I am just another doctor who
says they are fat and need to lose weight.
Dr. Pizzimenti said when discussing weight with patients, he chooses the
words he uses carefully.
We as primary eye care providers have a duty to counsel our
patients, without stigmatizing our using threatening techniques, he said.
I use terms like excess weight rather than obesity, and
physical activity rather than exercise.
Dr. Anshel said there is also one word he tries to avoid in patient
People tend to think diet is a four-letter word,
Stating the facts
Providing patients with new and often surprising
information about the link between their eyes and obesity can often move the
conversation from defensiveness and potential insult toward insight and
empowerment. Dr. Bohlman said after he has discussed BMI with a patient, he
explains the connection between obesity and eye health.
Most patients have heard of glaucoma, macular degeneration and
diabetic retinopathy, so I dont have to explain those conditions,
he said. I tell them that these conditions can cause them to lose vision
permanently, and that losing weight especially around the waist
will reduce their risk of losing vision.
Working with other practitioners
The next step aiding a patient in implementing a weight loss plan
often calls for cooperation from a patients primary care physician
or another professional.
The truth is, nobody can do it alone; everyone needs a
coach, Dr. Anshel said. I work with a nutritionist locally, and I
refer patients to her, and I get reports back. We work together well.
Dr. Bohlman said he recommends and refers patients to the nutrition
service at the hospital where he works.
However, if I were in private practice, I would certainly dictate
a letter to their PCP, he said. It not only provides good care for
the patient, but it promotes ones practice within the larger medical
Dr. Pelino said he does send this type of letter to a patients
primary care doctor.
I tend to write a detailed letter, explaining that I talked to the
patient about BMI and its correlation to eye health, he said.
Its also a team approach, so I recommend that they see a
Dr. Pizzimenti sees his role in helping patients maintain a healthy
weight as an extension of what the primary care doctor has likely already
We strive to reinforce concepts that the patients primary
care doctor has already introduced, adding that these measures will have a
beneficial effect on their eye health and quality of vision, he said.
On occasion, well refer the patient to a subspecialist or
Looking at underlying causes
Dr. Pelino said he also seeks to understand what may have caused the
patient to become overweight.
In some cases, it may be related to an eating disorder, but I
dont want to assume that, he said. Sometimes, patients may
gain weight due to systemic conditions such as hypothyroidism, or due to
medicines such as birth control, antidepressants or antipsychotics. Or they may
have anxiety, or have recently quit smoking. We want, if necessary, to go to
their doctor to make sure there arent underlying conditions.
Likewise, Dr. Anshel said the nutritionist he works with approaches
various aspects of a patients lifestyle when helping them lose
What she emphasizes is lifestyle enhancement thinking
positively, reducing stress, improving relationships, he said.
Its more about lifestyle coaching, rather than just focusing on
what they put in their mouths. by Jennifer Byrne
- Cumming RG, Mitchell P, Smith W. Diet and cataract: the Blue
Mountains Eye Study. Ophthalmology. 2000;107:450-456.
- Gardner TW, Gabbay RA. Diabetes and obesity: A challenge for every
ophthalmologist. Arch Ophthalmol. 2009;127(3):328-329.
- Gasser P, Stumpfig D, Schotzau A, et al. Body mass index in
glaucoma. J Glaucoma. 1999;8(1):8-11.
- Klein BE, Klein R, Sponsel WE, et al. Prevalence of glaucoma: The
Beaver Dam Eye Study. Ophthalmology. 1992;99:1499-1504.
- Leske C, Connel AM, Wu SY, et al. Risk factors for open-angle
glaucoma: the Barbados Eye Study. Arch Ophthalmol.
- Jeffrey R. Anshel, OD, FAAO, practices in Carlsbad, Calif., and is
the founder of the Ocular Nutrition Society and a PCON Editorial Board member.
He can be reached at 7040 Avenida Encinas, Suite 110, Carlsbad, CA 92011; (760)
931-1390; fax: (760) 944-1200; firstname.lastname@example.org.
- Hal R. Bohlman, OD, FAAO, practices at the James H. Quillen VA
Medical Center in Mountain Home, Tenn. He can be reached at PO Box 4000, Eye
Clinic (112E), Mountain Home, TN 37684; (423) 979-3510; fax: (423) 979-3530;
- Carlo J. Pelino, OD, FAAO, is an assistant professor at the
Pennsylvania College of Optometry at Salus University. He can be reached at
1200 West Godfrey Ave., Philadelphia PA 19141; (215) 276-6180;
- Joseph J. Pizzimenti, OD, FAAO, is an associate professor of
optometry at NOVA Southeastern University in Fort Lauderdale, Fla. He can be
reached at 3200 South University Drive, Fort Lauderdale, FL 33328; (954)
262-1474; fax: (954) 262-1818; email@example.com.