Optometrists are well suited to contribute to educating patients regarding diabetes (See "Diabetes: An Overview," right.): They already see much of the dia-betic population — those older than age 45 — and the condition has ocular manifestations, such as diabetic retinopathy (DR), that can lead to blindness.^1,2 Also, providing such education benefits the patient, in that they have an extra set of eyes — pun intended — looking out for them. This, in turn, can bind them to their O.D. and create referrals. Further, supplying diabetes education is good for the profession, as it cements optometry’s importance as members of the patient’s health care team.

In coming from a background of serving a high population of Native Americans, who are at a greater risk for diabetes, I’ve found that the most important treatment to prevent diabetic-related blindness is education on lifestyle.³ It is my belief, with more than 28 years of practice under my belt, that if patients are educated and understand the “why” behind treatment, they are more likely to be compliant. For most patients who have Type 2 diabetes, which accounts for the majority of diabetes in the United States, weight reduction, increased physical exercise and a change in diet is essential.^4,5 With that said, I have found that these questions provide the opportunity to prompt positive changes in diabetic patients’ behaviors.

Diabetes: An Overview

DIABETES MELLITUS is a metabolic disorder resulting from either an inadequate production of insulin, Type 1, or an inability of the body‘s cells to respond to insulin, Type 2.

TYPE 1 is an auto immune dysfunction involving the destruction of beta cells, which produce insulin in the islands of Langerhans of the pancreas.

 

TYPE 2 is a progressive condition due to the increasing inability of cells to respond to insulin, insulin resistance and decreased production of insulin by the beta cells. It’s highly linked to obesity, sedentary lifestyle and genetics. 

 

The linked comorbidities of diabetes are cardiovascular disease, hypertension, kidney disease, neuropathy, retinopathy, peripheral vascular disease and stroke.

Q: HOW MUCH EXERCISE IS NEEDED TO LOSE AND MAINTAIN WEIGHT LOSS?

A: At least 150 minutes of moderate aerobic activity (e.g., walking, jogging, biking, swimming, etc.), an hour and 15 minutes of hardy aerobic activity a week, or a combination of the two, is recommended for weight loss.⁶ Additionally, most people must decrease their caloric intake to lose weight. In general terms, to lose 1 and ½ pounds a week, one’s daily calorie intake must be decreased 500 to 750 calories.⁶ It’s important to talk with your primary care doctor before starting an exercise regimen, so you can ensure the activity you have in mind will not have any negative health effects. (For additional information, refer patients to bit.ly/2Ra5RHb .)

To maintain weight loss, activities that expend 1,500 to 2,000 calories per week are suggested.⁷ Additionally, 40 minutes, at minimum, of moderate to vigorous exercise at least three to four times a week is recommended.⁷ (For additional information, refer patients to bit.ly/31QYiY8 .)

In terms of when to exercise, one to three hours after eating is generally considered ideal, as this is when one’s blood sugar is likely high.⁸ (For additional information, refer patients to diabetes.org/healthy-living/fitness )

Q: WHAT TYPE OF EXERCISE CAN DECREASE BLOOD SUGAR?

A: Structured exercise that consists of aerobic exercise, resistance training (e.g., free weights, medicine ball use, etc.) or a combination of the two is associated with HbA 1c reduction in patients who have Type 2 diabetes.⁹ (For additional information, refer patients to bit.ly/3uzNtpR .)

Q: WHAT SHOULD I EAT TO KEEP MY DIABETES AT BAY?

A: Diabetic patients should maintain a diet of high fiber foods (e.g. fruits and vegetables); foods that have a low glycemic index (e.g. lentils and oats); and foods that contain chromium (e.g. meats and nuts) and magnesium (e.g. tuna and dark chocolate).¹⁰ Additionally, apple cider vinegar, mixed in water, and cinnamon extract can help mitigate the effects of carbohydrates.¹⁰ These are just guidelines, as every dietary need is highly individualized.

Of note: Nutrition counseling aimed at improving or maintaining glycemic targets, accomplishing weight management goals and bettering cardiovascular risk factors (e.g., blood pressure, lipids, etc.) within individualized treatment goals is suggested for all diabetic and pre-diabetic adults.¹¹ (For more information, refer patients to bit.ly/3uoHXWO and bit.ly/31Ug5Ok .) (Therefore, O.D.s should have resources available regarding dietetic care. One resource: bit.ly/3cUbMJ1 .)

Q: CAN I DRINK DIET SODA IF I HAVE DIABETES?

A: Diet soda should be limited or avoided. Drinking more than four cans (1.5 L)/week is linked with a more than two-fold risk of proliferative DR, which can cause blindness.¹² Advanced DR at first diagnosis is a major risk factor for developing sustained blindness.¹³

Q: HOW CAN YOU TELL BY LOOKING IN MY EYE THAT I HAVE DIABETES?

A: To put our expertise in layman’s terms: The same blood vessels that run through your heart and lungs and kidneys and fingers and toes also run through your eye. That is why an annual dilated eye exam and collaboration with your primary care doctor and diabetes management team is vital to ensure your diabetes is being properly managed.

Patient Resources

 

 Academy of Nutrition and Dietetics: bit.ly/3cUbMJ1

 

 American Diabetes Association: diabetes.org 

 

 Association of Diabetes Care & Education Specialists: diabeteseducator.org/living-with-diabetes

 

 Centers for Disease Control and Prevention: Diabetes: cdc.gov/diabetes/

 

 Diabetes Exercise News & Organisation: diabetes-exercise.org

 

 Diabetes Foundation: diabetesfoundationinc.org/self-manage/online-resources/

 

 Diabetes Research Institute Foundation: bit.ly/3cUcPZt

 

 International Diabetes Federation: idf.org/

 

 National Institute of Diabetes and Digestive and Kidney Diseases: niddk.nih.gov

 

Q: WHY IS MY VISION FLUCTUATING?

A: This can be a sign of blood sugar that is either too high or too low; the side effect of starting insulin treatment or diabetic eye disease, such as DR or PDR. (For more information, refer patients to bit.ly/2OxmQT4 , eyehealth.diabetes.org and bit.ly/3rY3gNx .) It’s helpful to provide a list of symptoms to report to the healthcare provider, such as black spots in the vision, fluctuation of vision from morning to night or any subconjunctival hemorrhages.

Q: WHAT SHOULD MY HBA 1C BE TO KEEP RETINOPATHY AWAY?

A: Patients who have a HBA 1c level threshold below 6.5% generally have little to no retinopathy.¹⁴ Duration of disease is one of the most important factors for the development of the eye condition. Greater than 15 years has an 80% risk factor of DR.¹⁵

INCREASING BUY-IN

By answering these questions, O.D.s can increase the likelihood that patients will pursue healthier lifestyles and, therefore, see a bright future in their diabetic care. For reinforcement, patients should leave with a checklist. OM

REFERENCES

1. Centers for Disease Control & Prevention: Diabetes and Prediabetes. https://www.cdc.gov/chronicdisease/resources/publications/factsheets/diabetes-prediabetes.htm . Accessed April 5, 2021.
2. Centers for Disease Control & Prevention: Type 2 Diabetes. https://www.cdc.gov/diabetes/basics/type2.html . Accessed April 6, 2021
3. Centers for Disease Control & Prevention: Native Americans with Diabetes. https://www.cdc.gov/vitalsigns/aian-diabetes/index.html . Accessed April 6, 2021.
4. Centers for Disease Control & Prevention: Diabetes Fast Facts. https://www.cdc.gov/diabetes/basics/quick-facts.html . Accessed April 6, 2021.
5. Fox CS, et al: Update on prevention of cardiovascular disease in adults with type two diabetes mellitus in light of recent evidence: a scientific statement from the American heart Association and the American diabetes Association, DIABETES CARE 38 (9):1777, 2015.
6. Mayo Clinic. Exercise for weight loss: Calories burned in 1 hour. https://www.mayoclinic.org/healthy-lifestyle/weight-loss/in-depth/exercise/art-20050999 . Accessed April 6, 2021.
7. Johns Hopkins Medicine. Health. Maintaining Weight Loss. https://www.hopkinsmedicine.org/health/wellness-and-prevention/maintaining-weight-loss . Accessed April 6, 2021.
8. Harvard Health Publishing. Harvard Medical School. The importance of exercise when you have diabetes. https://www.health.harvard.edu/staying-healthy/the-importance-of-exercise-when-you-have-diabetes . Accessed April 6, 2021
9. Umpierre D, Ribeiro PAB, Kramer CK, et al. Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: a systematic review and meta-analysis. JAMA. 2011;305(17):1790-9.
10. Semeco A. Healthline. 15 Easy Ways to Lower Blood Sugar Levels Naturally. https://www.healthline.com/nutrition/15-ways-to-lower-blood-sugar#TOC_TITLE_HDR_2 . Accessed April 6, 2021.
11. Evert AB, Dennison M, Gardner CD, et al. Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report. Diabetes Care. 2019 May;42(5):731-754.
12. Fenwick EK, Gan ATL, Man REK, et al. Diet soft drink is associated with increased odds of proliferative diabetic retinopathy. Clin Exp Ophthalmol. 2018 Sep;46(7):767-776.
13. Wykoff CC, Khurana RN, Nguyen QD, et al. Risk of Blindness Among Patients With Diabetes and Newly Diagnosed Diabetic Retinopathy. Diabetes Care. 2021 Mar;44(3):748-756.
14. Frank RN. Diabetic Retinopathy and Systemic Factors. Middle East Afr J Ophthalmol. 2015 Apr-Jun; 22(2): 151–156.
15. Retinopathy in Diabetes. care.diabetes.journals.org sent 4/12.

DR. ELLIOTT serves as the Government Relations Specialist for the Muskogee (Creek)Nation Tribe. She was named the Oklahoma Optometrist of the Year in 2014. Dr. Elliott is also an adjunct faculty member at the Northeastern State University Oklahoma College of Optometry and clinical optometrist with the Cherokee Nation.