Ophthalmologist as Lifestyle Guru?

Nutritional counseling may not be in your job description, but clinical data is leading some to conclude that it should be.

By René Luthe, Senior Associate Editor

The evidence keeps piling up that nutrition and other lifestyle choices affect ocular health. Not only in diabetes, infamously reaching epidemic proportions in the United States, but glaucoma and cataract as well. While more information is always welcome, does it obligate ophthalmologists to offer the “lifestyle counseling” that has previously been part of a primary care physician's role? As specialists, is it the ophthalmologist's job to simply “fix eyes” and move on?

As the role of lifestyle in ocular health continues to garner attention, Paul Koch, MD, of Warwick, RI, finds that his colleagues tend to fall into one of two camps: those who enthusiastically embrace talking with patients about nutrition and exercise, and those who think it is “voodoo.” Ophthalmologists, the latter maintain, already have a job that keeps them plenty busy — making people see better. But do the “voodoo doctors” have a point?

Yes, You Should Do It

Given the mountain of evidence demonstrating that lifestyle affects the most common, and significant, ocular disorders, why shouldn't the ophthalmologist counsel patients on their choices? The objections are typically these: Patients already hear all this from their primary care physicians, ophthalmologists aren't trained to do this, ophthalmologists are too busy, and you can't bill for it. But according to those advocating more of a holistic approach to care, those objections usually don't stand up well upon closer scrutiny.

Emily Chew, MD, deputy director of the division of epidemiology and clinical applications at the National Eye Institute, agrees that ophthalmologists are not trained to take much of a counselor's approach with their patients' health. “It's new territory for us, and I think we are a bit in the discomfort zone,” she says. Which may seem like a reason to leave the job for the PCP while you stick to fixing eyes. However, as some ophthalmologists have discovered, it is not safe to assume that the PCP is handling the nutrition/lifestyle angle — even with diabetic patients.

Larry Patterson, MD, of Crossville, Tenn., estimates that one-third to one-half of his diabetic patients claim that they have not been counseled about how diet affects their disease. When he asks them how they are treating diabetes, they reel off their medications. “I often tell them, no, that medicine is not to treat your diabetes, that medicine is to keep your sugar under control to the point where you won't die right away.” But the medicines, he maintains, should be more of a last resort, with glycemic control through diet being the primary weapon against diabetes. Dr. Patterson says his son is currently in medical school, where the emphasis is on prevention. When he meets a patient who hasn't been advised about diet, he explains the basics to them.

“We try to help the diabetics understand what sugar is, and that not all sugar is sweet, that if you eat a piece of white bread, that turns almost immediately into sugar,” Dr. Patterson explains.

Making sure patients understand that is essential to correcting some common nutritional misconceptions. For instance, many of his diabetic patients report having orange juice with their breakfast, believing anything made from fruit to be healthy. “I tell them that after all those years of Anita Bryant singing on the commercials, we got the impression that orange juice was really healthy, but it's not. It's sugar.” Similarly, they may believe that all vegetables are a very beneficial part of a healthy diet, but don't realize that “corn and potatoes are not, and you should avoid foods like that.”

His practice will sometimes refer patients to The South Beach Diet book so that they will have an inexpensive reference to guide them in their choices.

Another assumption you shouldn't make about PCPs is that they are any better trained in preventive medicine than you are, ophthalmologist Brian Will, MD, of Battle Ground, Wash., points out. Further, PCPs are not reimbursed for this sort of lifestyle advice either, and they know little or nothing about prevention of eye disease so it is quite possible that if the ophthalmologist doesn't address it, no one else will. Dr. Patterson adds another, all-too-human reason that the patient's PCP may not be sounding the lifestyle-choices alarm: “I've talked to a lot of family doctors, and their attitude is that no one listens to them anyway.”

So Why Would They Listen to You?

Some patients, indeed, will not. Patients who overeat and smoke have, if they've ever seen a doctor in their lives, been told that they should lose weight and quit smoking. As Dr. Koch notes, “Certain habits are completely addictive, and telling someone they have diabetes doesn't change the addictive nature of eating and smoking and drinking.”

Another group that is likely to resist is young diabetics, according to Bernie Milstein, MD, of Galveston, Texas. Patients in their teens and twenties don't want to adhere to a diet that will mark them as different from their peers. And there's the issue that at their stage of life, the long-term effects of diabetes are something they cannot conceive. “The immortality of youth,” Dr. Milstein says.

Yet an ophthalmologist's words may carry more weight with patients than other clinicians. As Dr. Chew notes, the fear of losing one's sight is extremely motivating. Patients don't need exposure to high-level educational courses to figure out that life with significantly impaired vision would be difficult. “Questionnaires have suggested that 70% of the American public are interested in keeping their vision. That's one of their top priorities when looking at the senses they could lose. They would rather lose a limb, or even trade a few more years of life for good vision. So vision is an important aspect of their quality of life.”

Dr. Will agrees, noting, “We have a unique opportunity to get people's attention.” When family members bring in elderly AMD patients, he says they often ask what they can do to keep from developing the disease themselves. “Fixing the epidemic of obesity, heart disease, strokes and other lifestyle-related diseases that adversely impact eye health and are devastating the American healthcare system requires that people assume personal responsibility for the own health,” Dr. Will says. He believes that changing the trajectory of our nation's health system starts with ophthalmologists assuming their ethical and medical responsibilities to improve people's lifestyle habits to help them avoid blindness from ocular diseases. “We can help people understand that they are not victims of bad genes or old age but rather that they can truly become the architects of their health and quality of life.”

Brad Oren, MD, of Lake Worth, Fla., thinks that it helps bolster ophthalmologists' cred that by the time patients are referred to them, the concept of “vision loss” has moved from the realm of theory to distinctly possible reality. The issues that are affected by weight that primary care physicians address, for instance, include risk of stroke, heart disease or high blood pressure sometime in the future. “But patients can't grasp really what it is going to do and when. When someone has macular degeneration that's relatively early in life, or they have diabetic retinopathy relatively early in life, and they are thinking they could lose their vision, it has a much bigger impact.”

What to Cover

If you choose to accept this mission, what, of all the diet and exercise information out there, should you communicate? Advocates advise keeping it simple — both in the interests of sticking to solid information and saving time. That means addressing:

• Sugar. Alas, it does appear to be public enemy #1. Informing patients about avoiding dramatic swings in glycemic levels and recognizing the sources of sugar in our diet and keeping weight at healthy levels is not just for diabetic patients. Dr. Chew notes that increased body mass index is associated with age-related macular degeneration.

Dr. Will agrees on the need to address weight control in AMD patients. “Many studies published in ophthalmology and journals of clinical nutrition show unequivocally that obesity, smoking, hypertension and sedentary lifestyle are not only contributing factors but probably the cause of macular degeneration.”

Drastic fluctuations in blood sugar affects cataract development, Dr. Koch notes, as poor sugar control activates a pathway that converts glucose into sorbitol. Sorbitol accumulates in the lens and attracts water, degrading the clarity of the lens. His colleague, Richard Sayegh, DO, says these fluctuations affect the lens “on a daily basis.” Over time, the result is cataractous changes at an earlier period than normal. “We are finding patients will come to us with cataract changes at a much younger age than patients without diabetes, so you can from that infer that tight blood sugar control, using lifestyle modifications, may indeed decrease the rate of cataract formations second-handedly,” he says.

To keep off weight and prevent drastic fluctuations in blood sugar, Dr. Oren recommends what he calls the “no box” diet. “It's very simple,” he explains. “If it comes in a box, don't eat it! Don't eat processed food, don't eat anything that has additives that makes it different from what it was on the farm. Is that always possible? No. But to the extent that it is, people should do it. It keeps the sodium down, it keeps the fat down, it keeps the artificial flavors and colors down, and it gives you more bulk and less calories.”

Dr. Will cites The China Study, by T. Colin Campbell, PhD, in discussing with patients the benefits of a healthy diet. Former US president Bill Clinton, he notes, famously lost 30 pounds by adopting such a diet. “It really is hard to be overweight,” Dr. Will says. “Look at rural China: There are no obese people, because they eat a whole-food, plant-based diet and live a less sedentary lifestyle than we do here.”

• The role of supplements. While these ophthalmologists were unanimous in their support for an AREDS-type vitamin supplement formulation for AMD patients, they were more reserved about their helpfulness for other ocular conditions. Dr. Chew, who chairs the AREDS2 study for NEI, says that she also likes to stress the importance a diet of varied, healthy foods. Leafy green vegetables and fish appear to be linked to reduced risk of macular degeneration, so incorporating those into the patient's diet appears to be a good step to take. “People always ask me if lutein is good, should they take that, should they take omega-3 oils? The answer is not in yet, as the randomized controlled trial is ongoing. But we do know with the dietary question that people who get a lot of that in their diet seem to have a lower risk of AMD,” she says.

Dr. Koch, a member of the advisory board for nutraceutical maker Science Based Health, is similarly circumspect. He believes that supplements are helpful for patients with certain dietary issues, but that they are merely one factor among many in maintaining health. Dr. Oren is wary of recommending supplements unless certain that the individual patient would benefit from them. “I generally don't push because it's not an eye-related problem and I think it's something they need to talk to their primary doctor and cardiologist about,” he says.

Dry eye is often another exception to the “diet is better” tendency. Jon Marc Weston, MD, of Roseburg, Ore., believes it is critical to offer these patients supplements that will aid them in lubrication. “Any ophthalmologist who doesn't is missing the boat,” he says.

• “Let's move.” It's a good idea to tout the virtues of exercise for ocular health, as well as general fitness. While many patients may object that they don't like it, Dr. Oren maintains that it is a matter of finding something you like and doing it for 20 minutes a day, three days a week — which certainly doesn't sound so bad. “Yoga, walking, swimming or dancing: there's all kinds of things people can do.” Dr. Patterson also believes that exercise is beneficial, but is concerned that diabetic patients for whom weight management is a concern will believe that exercise is sufficient to do the job. Diet, he says, is far more important for weight loss. “I've read a number of studies showing that when people exercised but did not modify their diet, they didn't lose any weight at all. As a rule, you don't get diabetes due to a lack of exercise.”

• Yes, smoking cessation. Surely everyone on the planet by now knows that smoking is one of the worst things you can do for your health. Do you really need to spend precious time telling patients what they already know? Given that smoking is indeed harmful to ocular health — contributing not only to glaucoma and dry eye, but also to cataract development and AMD — Jason Jones, MD, believes ophthalmologists should join the anti-smoking chorus.

Dr. Jones doesn't wait for ocular problems to develop. Even if a patient neglects to mention their habit on the patient history, he notes that the intimacy of the ocular exam usually makes it easy to to detect the tell-tale odor. He mentions to patients that he cannot help noticing the scent of tobacco on them and asks if they smoke. After commiserating with them about the difficulty of quitting, Dr. Jones acknowledges that though they have probably heard this before, stopping can have a significant impact on their visual function, both in the short and long-term. If the patient seems to resent his remark, he has a gentle follow up: “I'm just trying to give you other reasons to consider why you'd want to change things that are part of your life, and I feel this really is important for you,” he says. “I find giving patients and their family members ammunition in that battle to minimize risk factors is really important.”

• Start with yourself. Of course, to bring up such potentially delicate subjects with patients, it helps to be walking the walk yourself. Dr. Patterson recognizes its importance. “I'm on a diet. People look at me and think I'm fairly slender and in good shape; that's because I don't eat everything I want to eat. I have some restraint.” Getting staff onboard is helpful too, he says.

It is not as if the guidelines for a healthy diet and lifestyle are complicated, or controversial, Dr. Koch observes. “We know what the major factors are: exercise, eating healthfully — by that, I mean cutting out the saturated fats and cholesterols, choosing things with more unsaturated fats, making sure you get antioxidants, fibers and vitamins; cutting out alcohol as much as you can; not smoking.”

Nor is it a discussion that has to put you behind in your schedule, once you understand what the patient needs to hear about. “It isn't an hour-long discussion,” Dr. Oren says. “It's a two-minute discussion.”

Approaching the Discussion

Given that weight loss is frequently an issue in patient health, many ophthalmologists may be leery of “going there” — after all, patients may take offense at their eye doctor basically telling them they are overweight — yet according to Dr. Will, “it is and it isn't” a delicate conversation to initiate. “Most people are interested in health,” he points out, and weight loss is a big-money industry for a reason. “There aren't too many people out there who wake up in the morning thinking, ‘Man, I really wish I were 30 pounds heavier!’” He believes such conversations are easier to begin if you have nurtured a good doctor/patient relationship.

Dr. Chew agrees. “You have to know your patient to discuss systemic problems,” she says. “And always think of the patient as not just a pair of eyes, but as a patient who has systemic issues that you have to deal with, especially diabetic retinopathy and other ocular diseases.”

A detailed patient history questionnaire can make initiating discussions easier. A family history of eye disease can serve as an opening to discussing diabetes prevention and how crucial weight management is to that, or how quitting smoking can enable the patient to avoid AMD.

In his refractive surgery practice, Dr. Will notes that patients coming in for LASIK are interested in self-improvement anyway. Often, he says, they have gone through a divorce and want to look better, or are seeking a new career and wish to look younger in order to better compete in the job market. “There's a lot of background information that oftentimes gets ignored by our profession,” he says.

The possibility of being able to minimize or even stop the use of medication, with their often-unpleasant side effects, is an alluring hook, many find. “No one is going to be offended by a conversation about ways they can get off their hypertensive, cholesterol or hypoglycemic medications,” Dr. Will says.

Dr. Chew notes that strict glycemic control yields results that drugs, thus far, cannot deliver. “In fact, tight glycemic control can result in 70% reduction in the progression of diabetic retinopathy. Clearly, other ocular treatments may not achieve such a large beneficial effect.” Dr. Chew says.

To improve your chances of getting through to patients, Dr. Jones advises being painfully specific about just what the “vision loss” they might suffer if they don't change their ways would mean in real-life terms. “We ophthalmologists tend to talk to ourselves, but you need to relate vision loss to what they do in their lives, and what they wouldn't be able to do anymore. Do they want to be able to read a book, write their own checks, pay their own bills? Do they still want to be able to drive? Do they want to enjoy seeing their grandkids?”

Just setting aside the time to have a discussion about issues the ophthalmologist doesn't normally address is enough to get many patients' attention. “I think they recognize that I'm doing something that we don't ordinarily do. It's not that I'm trying to scare them, but I'm trying to communicate the importance of what diet can do for them,” says Dr. Milstein.

These Will Make It Easier

The ophthalmologists advocating a more holistic approach emphasize that not only is a long conversation not required of you, but also that there are other, low-cost sources you can incorporate to reinforce the message.

Paperback copies of The South Beach Diet are available cheap at most Wal-Marts, Dr. Patterson says. “Even if they don't read the whole book, they can read the first chapter and understand why so many people are having so much trouble with diet, and why so many people have diabetes.”

Dr. Will includes a nutrition/preventive medicine segment among the educational videos shown in the reception area and has also trained patient counselors to address the issue. Mainstream media documentaries, such as CNN's “The Last Heart Attack” (http://sanjayguptamd.blogs.cnn.com/2011/08/29/sanjay-gupta-reports-the-last-heart-attack) are patient-friendly ways to broach the subject.

But especially given that you are pressed for time, you can gauge if the patient — diabetic patients, at least — really need to hear about nutrition, Dr. Koch says. He asks his diabetics if they know their A1c level. The majority do. “If someone comes in and their A1c is 6.2, they are in pretty good control and I don't get involved. But if someone comes in, their vision is dropping and their A1c is 12, I will have a chat with them,” Dr. Koch says.

A study by the DRCR Network (discussed in this issue) is studying the impact of in-office education on A1c levels.

Worth the Effort

There remains, of course, the problem of not being able to bill for nutrition/lifestyle counseling. As practical a concern as that may be, many ophthalmologists have little patience for it. Dr. Oren believes that it is “an absolute necessity” to inform patients how they can improve their health. “They don't need us to tell them that their macular degeneration is worse or better, or what their pressure is in glaucoma, if we are not doing anything to change it,” he maintains. “If all we are doing is putting a needle in their eye and injecting them with Lucentis because we are getting paid for it, and not talking to them about the other things that can help just as much, maybe more, because we don't get paid for that, then we are not doing our job.” Dissatisfaction with the reimbursement situation, he says, should be addressed on the legislative level instead of used to justify inaction.

Dr. Patterson feels that the dire results of diabetes demand a better-safe-than-sorry approach. “Maybe patients didn't get on insulin and we start seeing their eyes fall apart, we start seeing fingers, toes, feet being amputated. It's one thing after another and it's a real bad downhill course. We've got to give them the information they need.”

While they've very likely heard it before somewhere along the line, reinforcement from every healthcare provider they encounter is crucial. Dr. Jones regards it as further ammunition to help patients go in a direction that is good for them. He reiterates that it requires little time. “It's not a big part of my practice, but it is very valuable.”

There are other payoffs too. Dr. Weston finds the better patient compliance and follow up that the counseling brings makes up for the lack of reimbursement. “We are convincing them that they need to be monitored and tested.” OM