Nutrition in the future of primary-care optometry

While the science of nutrition has been evolving for years, its role in patient care has long remained elusive. Understanding the importance of food intake can have clinical implications for the modern practice of optometry and medicine.

The 21st-century movement toward patient-driven health care is driving the use of mobile health applications (apps), artificial intelligence (AI), and wearable technologies. 

ODs are integral to the care of chronic diseases like diabetes, hypertension (HTN), age-related macular degeneration (AMD), and dry eye disease (DED). Primary-care ODs use innovative technologies to educate patients about their own health and use food and nutritional advice to improve their outcomes. 

Furthermore, optometric practices that develop expertise in nutrition can differentiate themselves through the delivery of high-level, preventive eye care.

Previously by Dr. Wong: Is optometry ready for the age of smartphone imaging? 

Benefits of apps/tech
Mobile apps and technology empower consumers with information to be more proactive in monitoring their own health.

One example includes the low FODMAP (fermentable oligosaccharide disaccharide monosaccharide and polyols) app from Monash University, which makes consumers more conscientious and self-aware of their behavior.¹

Proper awareness supports action, encourages positive health behavior and preventive measures (including the MyFitnessPal and Nike Training Club apps), and helps guide consumers to a better assessment and decision-making with particular health situations (MyGiHealth GI Symptom Tracker App).^2-4

Platforms for monitoring wellness include: 

Activity/exercise logs

Nutrition and caloric intake 

Amount and quality of sleep 

Personalized food recommendations

Related: How to guide patients in the use of digital devices

Fitness and optometry 
Optometrists in sports vision have taught the importance of advances in performance technology. 

Additionally, the use of integrated mobile health technology and wearable AI technology is growing exponentially.⁶

Elite athletes in sports such as tennis, baseball, basketball, and soccer train and recover with the aid of new technologies, improved diets, and proper sleep patterns. 

ODs are finding lessons that can be translated to all patients who want to live longer, healthier, and more active lives. Smart watches, Fitbits, and other monitoring devices are technologies ODs should understand to better educate and care for patients.⁷

Related: Innovative mobile technology targets low vision 

Food as medicine
“Food as medicine” is a growing movement redefining views on the science of nutrition and medicine’s role in using dietary recommendations to manage chronic health conditions like diabetes, HTN, Crohn’s disease, colitis, irritable bowel syndrome (IBS), and small intestinal bacterial overgrowth (SIBO) syndrome.⁸

Healthcare systems-such as Mount Sinai in New York City-are investing and partnering with healthcare companies like Epicured, a subscription meal delivery service specializing in low FODMAP and gluten-free prepared foods.⁹

In 2017, Mount Sinai’s Division of Gastroenterology performed a clinical review of Epicured’s food product. It has since provided food services to deliver low FODMAP meals to the healthcare system’s patients.⁹

A low FODMAP diets consist of meals without garlic, onions, milk, apples, and up to 10 mg of celery. 

While there are other restrictions, the diet is 70 percent effective in reducing IBS.¹⁰Related: How diet and nutrition affect disease 

What to recommend to patients
Patients often ask questions of their eyecare practitioners about the relationship between nutrition and eye health. Although the age-related eye disease study (AREDS) and role of antioxidants in the management of patients with AMD is well documented, more evidence-based studies with clinical applications to the art and science of optometry are needed.¹¹

In relation to general eye health questions, both the National Eye Institute (NEI) and American Optometric Association (AOA) have long offered educational resources. 

Two of the four recommendations by the NEI to keep your eyes healthy are:¹²

Eat right to protect eye sight
Eating a diet rich in fruits and vegetables, particularly dark leafy greens such as spinach, kale, or collard greens, is also important for keeping eyes healthy. Research has also shown there are eye health benefits from eating fish high in omega-3 fatty acids, such as salmon, tuna, and halibut.
 

Related: Omega-3s no better than placebo for dry eye 

Maintain a healthy weight
Being overweight or obese increases the risk of developing diabetes and other systemic conditions, which can lead to vision loss, such as diabetic eye disease or glaucoma.

The AOA has a webpage on diet and nutrition with recommendations to add antioxidants and nutrients to diets under certain conditions.¹³

The AOA also provides pamphlets and other educational materials educating ODs and the public about the eye and nutrition.

Organizations providing information on the importance of nutrition in eye health include the American Diabetes Association (ADA), American Public Health Association (APHA), and the Ocular Wellness and Nutrition Society (OWNS).^14-16

OWNS provides informational and educational resources to healthcare professionals, the public, and the media on the relationship between nutrition and ocular health.

Related: 6 healthy habits that don't cost a fortune 

Nutrition and chronic disease
A healthy diet and lifestyle promotes the prevention and reversal of chronic diseases.  

Seven out of the 10 leading causes of death are directly related to dietary choices:¹⁷

diabetes

Heart disease

Cancer

Lung disease

Cerebrovascular disease (CVD)

Alzheimer’s disease

Kidney disease

Eighty percent of chronic disease can be prevented with simple lifestyle habits and putting nutrition at the top of the list.¹⁸

CVD
Red and processed meat consumption are associated with an increased CV risk; those following a vegetarian diet have a decreased risk of mortality¹⁹

Fruits and vegetables lead to CV risk reduction  

diabetes
Processed meat consumption is linked to an increased risk of diabetes

Eating whole grains and fruit decreases risk of diabetes mellitus (DM), micro-, and macro-vascular complications 

Hyperglycemia impairs the regulation of retinal perfusion; it is important to manage glucose levels to avoid complications of retinal perfusion²⁰Related: Understand diabetes and nutrition 

Cancer
Red meat increases risk of colorectal cancer²¹

Whole grains, fruits, and vegetables are associated with a significant reduction in total cancer risk

Chronic eye disease
Dietary antioxidants and anti-inflammatories help decrease the risk of age-related eye disease and help deter the progression of other chronic eye diseases.²²

Dry eye
Omega-3 rich diets result in neuroprotective effects, help with tear osmolarity, improve tear quality, and reduce meibomian gland dysfunction (MGD).²³

Related:

Examples of omega- 3 fatty acids in food include:

Fish and shellfish (mackerel, salmon, cod liver oil, herring, oysters, sardines, anchovies, caviar)

Seeds (flaxseeds, chia seeds) 

Nuts (walnuts)

Related: 

AMDCarotenoids: Certain antioxidants-carotenoids-reduce the effect of free radicals on the macular pigment and help with retinal pigment layer thickening. A diet high in carotenoids can also delay the advancement of AMD.²⁴

Beta carotene: Carrots, sweet potato, dark leafy greens, red and yellow peppers. 

Lutein: Dark, leafy veggies (spinach, collard greens, kale). 

Zeaxanthin: Dark, leafy veggies (spinach, collard green, kale).

Vitamin C: Kiwi, citrus fruits, mango, papaya (also helps prevent cataracts)

Vitamin E: Vegetable oils, nuts, green vegetables. Should be taken in combination with other vitamins and minerals listed here; taken alone not beneficial for AMD.²⁵

Zinc: Brings Vitamin A from liver to retina to produce melanin (meat, shellfish, legumes, eggs, whole grains, seeds).

Copper: Nuts, seeds, leafy greens, oysters, organ meats.

Related: Consider the underrated significance of vitamin K2 in eye care 

Patient education
Using diet to address underlying chronic disease can help with the management of chronic eye diseases and improve patient health outcomes.

Diabetic retinopathy/cataracts/ glaucoma 
Recommend a diabetic diet to manage blood sugar and minimize microvascular damage, such as dietary fiber, oily fish, a Mediterranean diet, and a reduced caloric intake; they are associated with lower risk of diabetic retinopathy (DR).²⁶Related: ODs must teach patients about proper nutrition 

Patients at risk for HTN retinopathy
Manage with a low-sodium diet to help decrease HTN retinopathy, pressure on blood vessels, retinal edema, and swelling of the optic nerve.²⁷

Future of food
What is the future role of optometry in altering the nutritional patterns of diverse patient communities? 

The rapid rise of diabetes and HTN in the nation’s population is considered to be tied to poor diet and lifestyle choices. Will the role of diet and nutrition become a more integral part of the optometric care of cataracts, glaucoma, and DED?  

Read more technology articles here 

References:

1. Monash University. Your complete on-the-go guide to the FODMAP Diet. Available at: https://www.monashfodmap.com/ibs-central/i-have-ibs/get-the-app/. Accessed 9/11/19.

2. My FitnessPal. Lose Weight with MyFitnessPal.com-for FREE! Available at:  https://www.myfitnesspal.com/welcome/learn_more. Accessed 9/11/19. 

3. Nike. Nike Training Club App. Available at: https://www.nike.com/us/en_us/c/nike-plus/training-app. Accessed 9/11/19. 

4. Apple. My GiHealth GI Symptom Tracker. Available at: https://apps.apple.com/us/app/mygihealth-gi-symptom-tracker/id964527560. Accessed 9/11/19. 

5. American Optometric Association. Sports & Performance Vision. Available at: https://www.aoa.org/optometrists/tools-and-resources/sports-and-performance-vision. Accessed 9/11/19. 

6. Mischke J. The State of Wearable Technology in Healthcare: Current and Future. Wearable Technologies. Available at: https://www.wearable-technologies.com/2018/10/the-state-of-wearable-technology-in-healthcare-current-and-future/. Accessed 9/11/19. 

7. Wearable Technologies. Wearable Technologies Show 2019 MEDICA. Available at: https://www.wearable-technologies.com/events/wt-wearable-technologies-show-2019-medica/. Accessed 9/11/19. 

8. Food is  Medicine Coalition. The Medically Tailored Meal Intervention. Available at: http://www.fimcoalition.org/our-model. Accessed 9/11/19. 

9. Mount Sinai. Mount Sinai Health System and Epicured Partner to Bring Culinary Cures to Patients. Available at: https://www.mountsinai.org/about/newsroom/2019/mount-sinai-health-system-and-epicured-partner-to-bring-culinary-cures-to-patients. Accessed 9/11/19. 

10. Stanford Health Care. Low FODMAP Diet: Our Approach to the Low FODMAP Diet. Available at: https://stanfordhealthcare.org/medical-treatments/l/low-fodmap-diet.html. Accessed 9/11/19. 

11. National Eye Institute. What the Age-Related Eye Disease Studies Mean for You. Available at:  https://nei.nih.gov/areds2/PatientFAQ. Accessed 9/11/19. 

12. National Eye Institute. Healthy Eyes. Available at: https://nei.nih.gov/health/healthyeyes/healthyeyes. Accessed 9/11/19. 

13. American Optometric Association. Diet & Nutrition. Available at: https://www.aoa.org/patients-and-public/caring-for-your-vision/diet-and-nutrition. Accessed 9/11/19. 

14. American Diabetes Association. Nutrition: Eating doesn’t have to be boring. Available at: http://www.diabetes.org/food-and-fitness/food/. Accessed 9/11/19. 

15. American Public Health Association. Food and Nutrition. Available at: https://www.apha.org/apha-communities/member-sections/food-and-nutrition. Accessed 9/11/19. 

16. Ocular Wellness and Nutrition Society. Mission Statement. Available at: https://www.ocularnutritionsociety.org/mission-statement. Accessed 9/11/19. 

17. Centers for Disease Control and Prevention (CDC). National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP): Chronic Disease in America. Available at:  https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.htm. Accessed 9/11/19. 

18. World Health Organization (WHO). Chronic disease and health promotion: Overview-Preventing chronic diseases: a vital investment. Available at: https://www.who.int/chp/chronic_disease_report/part1/en/index11.html. Accessed 9/11/19. 

19. Physicians Committee for Responsible Medicine. Red Meat Increases Heart Disease Risk. Available at: https://www.pcrm.org/news/health-nutrition/red-meat-increases-heart-disease-risk. Accessed 9/11/19. 

20. Grunwald JE, Brucker AJ, Schwartz SS. Braunstein SN, Baker L, Petrig BL, Riva CE. Diabetic glycemic control and retinal blood flow. Diabetes. 1990 May;39(5):602-7.

21. Aykan NF. Red Meat and Colorectal Cancer. Oncol Rev. 2015 Feb 10; 9(1):288.

22. Rasmussen HM, Johnson EJ. Nutrients for the aging eye. Clin Interv Aging. 2013 Jun;8: 741-748.

23. Faulkner WJ. The Role of Omega-3 Essential Fatty Acids in Dry Eye Disease. Int J Clin Exp Ophthalmol. 2017 Dec 22;1:055-059. 

24. American Optometric Association. Nutrition and Age-Related Macular Degeneration. Available at: https://www.aoa.org/patients-and-public/caring-for-your-vision/nutrition/nutrition-and-age-related-macular-degeneration. Accessed 9/11/19. 

25. Harvard T.H. Chan School of Public Health. The Nutrition Source: Vitamin E. Available at: https://www.hsph.harvard.edu/nutritionsource/vitamin-e/. Accessed 9/11/19. 

26. Wong MYZ, Man REK, Fenwick EK, Gupta P, Ling-Jun L, van Dam RM, Chong MF, Lamoureux EL. Dietary intake and diabetic retinopathy: A systematic review. PLoS One. 2018;13(1): e0186582.

27. Harvard Health Publishing. Retinopathy.  Available at: https://www.health.harvard.edu/a_to_z/retinopathy-a-to-z. Accessed 9/11/19.