Given the established link between diabetes risk and unhealthy weight, a lack of physical activity, and high cholesterol,¹ it is important for optometrists to be knowledgeable on these factors to benefit their diabetic patients. Weight loss, nutrition, physical activity, sleep, and stress reduction can all play an important role in diabetes management.

This article explores the optometrist’s role in facilitating nutrition and lifestyle changes in the diabetic patient. Specifically, I review the most important changes and share effective ways to motivate our patients to adopt these changes.

WEIGHT LOSS & PHYSICAL ACTIVITY

Excess weight gain is one of the fundamental causes of Type 2 diabetes. The risk of developing diabetes increases seven-fold in overweight people, and 20-fold to 40-fold in obese people.² According to the Harvard School of Public Health, losing 7% to 10% (i.e., 10 pounds to 15 pounds) of one’s current weight can reduce their chances of developing Type 2 diabetes by as much as 50%.³

The American Diabetes Association recommends 150 minutes of moderate intensity exercise per week for adults. Ideally, this means exercising five to six days per week or not letting more than 48 hours go between exercise sessions. If time is an issue, there is even proven benefit from being active for 10-minute intervals three times per day.

Some patients may have trouble committing to exercise because they see it as “work.” In this case, you can suggest ways to make exercise more fun such as enlisting a friend, listening to your favorite music, or watching your favorite TV show while exercising.⁴

Here are some examples of moderate intensity exercise:

• Brisk walking
• Bike riding
• Swimming
• Jumping rope
• Using a rowing machine
• Functional workouts: Squats, jumping jacks, planks
• Taking up an aerobic sport, such as pickleball or kayakingWithout proper support and guidance, many patients struggle to implement the necessary changes for weight loss. Here are some examples of questions that can help to motivate patients with diabetes to make positive lifestyle changes.⁵
• “How ready do you feel to change your eating patterns and/or lifestyle behaviors?”
• “What kinds of things have you done in the past to add more nutritious foods to your diet?”
• “What types of physical activity do you enjoy?”

If a patient responds that they are not ready to change their eating patterns or lifestyle, you can ask them if they know what may be holding them back from such changes. You can also remind patients that they can decide to make small changes to their lifestyle at any time.

For more advice on how to work such questions into the patient visit, see the sidebar “What to Ask, and When, During A Patient’s Visit,” on p.34.

NUTRITION

Nutrition therapy is an important part of managing diabetes. There is no single diet recommended for people who have diabetes, and each person’s macro-nutrient needs are different. For this reason, it’s important to include a dietitian or diabetes educator in the patient’s management; I recommend reaching out to local specialists and providing them information about your practice and your role in diabetes care.

These dietitians and educators can help you formulate meal plans that include nutrient-dense foods in the proper serving sizes. Doing so helps to improve A1C and cardiovascular health, achieve weight loss goals, and delay or prevent complications of the disease.⁶

While each patient’s needs are different, healthy diets are typically ones that promote stable blood glucose levels, are rich in non-starchy vegetables and fruits, and low in saturated/trans fats, sodium, added sugar and refined grains. Optometrists should encourage patients to consume foods high in nutrients important for ocular health, including lutein, zeaxanthin, vitamin C, and omega-3 fatty acids. For specifics on the foods in which these nutrients can be found, see “Healthy Foods for Patients with Diabetes,” p.36.

As for carbohydrates, the regular intake of sufficient dietary fiber is associated with lower all-cause mortality in people who have diabetes. Furthermore, a diet rich in whole grains vs. refined grains is associated with a reduced risk of Type 2 diabetes. Refined grains, among other processed food, are directly linked with an increased risk of diabetic disease.⁶

Thus, all patients should replace refined grains with whole-grain foods. Despite the health benefits of whole grains, their caloric content often can be comparable to refined grains, so it is important to be mindful of proper serving sizes. One serving of grains is ½ cup cooked rice or 1 slice of bread, and at least three servings per day of whole grains are recommended.⁷

SLEEP

There is evidence that the duration and quality of sleep influences the severity of Type 2 diabetes. Additionally, lack of sleep can have a negative affect on weight gain.⁸ We can counsel our patients about the effects of blue light and electronic device use on the quality of their sleep, and remind our patients to turn off screens two hours before bed.⁹

WHAT TO ASK, AND WHEN, DURING A PATIENT’S VISIT

Education about nutrition and lifestyle should be included in every diabetic eye exam. There are various points throughout the eye examination for this to occur.

1 PATIENT INTAKE:

When the patient first arrives, you can ask them about their nutrition and wellness routine. A few sample topics are:

• Current fruit and vegetable intake (“How many servings of vegetable and fruit do you eat per day?”)
• Whether the patient is regularly seeing a registered dietitian, diabetes educator, or other nutrition specialist
• Whether the patient is following any specific diet or food plan
• Whether the patient has lost weight in the past year or has any weight loss goals
• How many minutes per week the patient is physically active

2 DURING EXAMINATION:

Optometrists should utilize OCT and retinal photography and review images with the patient to educate them regarding the relationship between control of blood sugar and the potential for existing diabetic retinopathy. This is important because the possibility of vision loss or change is often the motivator that patients need to make a change.

3 TREATMENT PLAN AND PATIENT COUNSELING:

By this part of the eye examination, the patient will be expecting guidance on how to proceed with lifestyle and nutrition changes. My suggestions:

• Start with recommendations on eye healthy foods that they can include in their diet.
• Discuss the importance of 150 minutes per week of moderate physical activity, and ask about fitness goals. Provide a list of local fitness providers, and certified personal trainers.
• Provide resources or a referral to a local registered dietitian or diabetes educator.

MENTAL HEALTH

As we educate our patients about lifestyle and nutrition changes they can make to help manage their diabetes, it is important for us to be mindful that they may be feeling scared, stressed out, sad, or anxious. So, as we develop and deliver our treatment plan to our patients who have diabetes, it is important to be empathetic to their individual journey.¹⁰

You can show empathy by letting your patient know that you are listening by paraphrasing their concerns and nodding in acknowledgment with what they say. Show curiosity about how their symptoms affect their life.

Additional ways for patients to curb stress and anxiety include seeking the help of a mental health professional, adopting daily habits, such as meditation and mindful walking, and spending time with supportive friends and family members.

HEALTHY FOOD FOR PATIENTS WITH DIABETES

Encourage your patients to fill their plates with eye-healthy fruits and vegetables like the following, which are high in lutein, zeaxanthin, vitamin C, vitamin E, omega-3 fatty acids, and fiber.

• One handful of raw leafy greens such as kale, spinach, collard greens, per day.
• Half cup cooked leafy greens twice per week.
• Two orange peppers per week, both raw (to absorb more vitamin C) and cooked (to absorb more zeaxanthin and lutein).
• Half cup green vegetables per day, such as raw or cooked broccoli, Brussels sprouts, green peas, green beans, asparagus, or zucchini.
• Up to three servings of kiwi, avocado, cantaloupe, citrus fruit, or berries per day. One serving of fruit is ½ cup.
• Avoid fruit juice and dried fruits, as they are high in sugar.
• Include whole grains into your daily diet. Good choices include quinoa, barley, whole grain bread, and whole grain pasta. Monitor serving sizes. One serving is 1/2 cup cooked or 1 slice of bread.
• Choose lean meat and poultry, such as turkey breast, chicken breast, or lean cuts of beef.
• Eat two to three servings per week of cold-water fish, such as salmon, rainbow trout, sardines, or mackerel. One serving of fish is 100 grams.
• Use healthy oils, such as olive oil or avocado oil, for salad dressings and cooking.

The American Diabetes Association also has an online resource of nutrition information for people with diabetes. It is viewable at bit.ly/ADAeatingwell .

Source: Capogna, Laurie. “Eyefoods: The Complete Eye Health and Nutrition Guide.” Toronto. Robert Rose Publishing. 2019.

HEALTHY HABITS AT YOUR OFFICE

Finally, optometrists should remember to set an example by having their office adopt healthy habits. For example, consider encouraging healthy snacks (such as apples, orange peppers, or hummus), and designating a wellness room in your office where staff members can do light physical activity.

Let’s change the way we think and talk about food. It is the fuel for our bodies. This will help us to inspire others to make positive changes in their diet and lifestyle, so that they can maintain a lifetime of healthier eyes. OM

REFERENCES

1. Preventing Diabetes-Related Complications. Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/data/statistics-report/preventing-complications.html . Updated September 30, 2022. Accessed February 11, 2014.
2. Hu FB, Manson JE, Stampfer MJ, et al. Diet, lifestyle, and the risk of type 2 diabetes mellitus in women. N Engl J Med. 2001;345:790-797.
3. Harvard School of Public Health. Simple Steps to Preventing Diabetes. www.hsph.harvard.edu/nutritionsource/preventing-diabetes-full-story/ . Accessed February 11, 2014.
4. American Diabetes Association. Fitness. diabetes.org/healthy-living/fitness . Accessed February 11, 2014.
5. DiLillo V, Siegfried NJ, Smith West D. Incorporating Motivational Interviewing Into Behavioral Obesity Treatment. Cognitive Behavioral Prac. 2003;10:120-30.
6. Evert AB, Dennison M, Gardner CD, et al. Nutrition Therapy for Adults with Diabetes or Prediabetes: A Consensus Report. Diabetes Care. 2019;42:731-754.
7. United States Department of Agriculture. Dietary Guidelines for Americans 2020-2050. https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdf . Accessed April 7, 2023.
8. Knutson KL, Ryden AM, Mander BA, Van Cauter E. Role of sleep duration and quality in the risk and severity of type 2 diabetes mellitus. Arch Intern Med. 2006;166:1768–1774.
9. Tosini G, Ferguson I, Tsubota K. Effects of blue light on the circadian system and eye physiology. Mol Vis. 2016;22:61-72.
10. American Diabetes Association. Mental Health. https://diabetes.org/healthy-living/mental-health . Accessed February 11, 2014.

DR. CAPOGNA owns her practice, Eye Wellness in Niagara Falls, Canada. She is the author of “Eyefoods: The Complete Guide to Nutrition and Eye Health.” She is passionate about educating and inspiring her patients and colleagues on the power of lifestyle and nutrition in maintaining healthy eyes.