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Chous & Richer Obesity Related Eye Disease and Patient Communication
American Pie Meets American Idle:
Nutritional and Nutraceutical Management of Obesity Related Eye Disease
A. Paul Chous, MA, OD, FAAO
Stuart P. Richer, OD, PhD, FAAO
A. Paul Chous, MA, OD, FAAO
25300 Lake Wilderness CC Drive SE
Maple Valley, WA 98038
[email protected]
Stuart Richer, OD, PhD, FAAO
Eye Clinic 112e
DVA Medical Center
North Chicago, IL 60064
[email protected]
ABSTRACT
Surveys indicate that patients place high value on Primary Care Providers who discuss
lifestyle issues such as weight maintenance, exercise and supplementation. Given the obesity
and diabetes epidemic, ODs have a Public Health responsibility to proactively address these
issues. We discuss the biologic rationale for specific macronutrients, micronutrients and
exercise with respect to weight maintenance and loss, insulin resistance, inflammation,
oxidative stress, and obesity related cardiovascular and eye disease. Scientific rationale and
effective Patient-Doctor communication are stressed, with patient recommendations
integrated within the presentation and handout.
I. Course Considerations
a. Why is obesity associated with ophthalmic (and systemic) disease?
b. Clinical Entities
c. Epidemiology and Definitions
d. Biological Rationale for Specific Macronutrients
1. Dietary Fat
2. Dietary Carbohydrate & Fiber
 Carbohydrate Metabolism: a link between AMD & Diabetes
3. Dietary Protein
e. Biological Rationale for Specific Micronutrient and Nutraceutical Supplements
h. Some Recommendations
1. Dietary
2. Supplementation
3. Patient communication
i. Conclusion
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Chous & Richer Obesity Related Eye Disease and Patient Communication
II. Why is obesity associated with ophthalmic (and systemic) disease?
An Unholy Triumvirate: Inflammation, Hypertension and Hypoxia
a. Inflammation, Insulin Resistance and Oxidative stress (see Figure 1)
Inflammation
- Fat cells are endocrine cells, secreting hormones that regulate insulin
sensitivity and satiety (‘fullness’) & inflammatory proteins
- Visceral fat surrounding internal organs, in particular, worsens insulin
sensitivity and increases appetite leading to a vicious cycle of high caloric
intake, insulin resistance and increasing adiposity
- visceral and subcutaneous fat are associated with elevated markers of
inflammation, including C-reactive protein (CRP), intracellular adhesion
molecules (ICAMs) and fibrinogen
 CRP destabilizes atherosclerotic plaques
 ICAMs cause white blood cell adhesion to blood vessel walls
 Fibrinogen promotes formation of platelet clots
 inflammation causes endothelial dysfunction and increased
insulin resistance, leading to vascular diseases, including eye
disease
Insulin Resistance
- Obesity without inflammation does not cause insulin resistance
- Some tissues do NOT require insulin to get glucose inside of cells:
 liver
 kidney
 aorta
 retina
- insulin resistance leads to high levels of intracellular glucose within these
insulin independent tissues
- mitochondrial exposure to high levels of glucose causes over-production of
reactive oxygen species (ROS)
- in addition, visceral fat mobilizes serum free fatty acids (FFAs) that are also
oxidized by mitochondria within vascular endothelium to generate ROS
Oxidative Stress
-
increased ROS lead to vascular complications via four
distinct biochemical pathways
1.
2.
3.
4.
Polyol
Hexosamine
Advanced Glycation Endproducts
Protein Kinase C
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Chous & Richer Obesity Related Eye Disease and Patient Communication
- Free iron is locally toxic to body tissues, which have developed a host of
serologic mechanisms to capture and sequester iron
- Iron overload may result from metabolic defects, diet or specific genes
- Iron metabolism is adversely affected by hyperglycemia, leading to
inflammation, insulin resistance and oxidative stress in type 2 diabetes and
the metabolic syndrome
- Stores of the iron-sequestering plasma protein, haptoglobin (Hp) are elevated
in diabetes and Hp genotype appears to confer increased/decreased risk of
diabetic retinopathy in T1DM and cardiovascular events in T2DM*
* Haptoglobin PCR genotyping is available through ARUP Laboratories @
http://www.aruplab.com/guides/ug/tests/0040116.jsp
Iron
Overload
Metabolic
Defects
Inflammatory
Cytokines
Figure 1
TNF-a
PAI-1
ICAMs
CRP
Haptoglobin
Genotype
Diet
Free Fatty Acids
Adipokines
Obesity
Visceral
Fat
Insulin
Resistance
Increased
Oxidative
Stress
Skeletal muscle
Liver
Hypothalamus
Hunger
&
Increased
Caloric
Intake
Blunted
Satiety
Receptors
Disease
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Chous & Richer Obesity Related Eye Disease and Patient Communication
b. Hypertension
- Obesity and body mass index (BMI) are clear and continuous risk factors for
HTN
- risk of hypertension increases linearly with VAT
- weight loss clearly results in reduced BP in large clinical trials
- HTN is a definitive risk factor for myriad posterior segment diseases
(e.g. hypertensive retinopathy, retinal vascular occlusions, diabetic
retinopathy, AION)
c. Obstructive Sleep Apnea Syndrome (OSAS)
- increased BMI and type 2 diabetes are the two most common, independent
systemic risk factors associated with OSAS
- OSAS activates the renin-angiotensin system, increasing blood pressure
- OSAS causes hypoxic stress, endothelial dysfunction, increased platelet
aggregation and adhesion of inflammatory proteins that significantly increase
the risk of vascular disease, including eye disease (glaucoma, NAION,
pseudotumor cerebri)
III. Clinical Entities
a. Cataract
– risk of Cataract is 30% to 40% higher in patients with Metabolic Syndrome
- risk of posterior subcapsular cataract is 4x greater for women with diabetes
and 2x greater for women with BMI > 30 (versus <25) and increased waist
circumference (>89cm versus <80cm)
- BMI > 30 associated with increased risk of cortical cat and PSC in the
Blue Mountains Eye Study
b. Glaucoma, NAION, Floppy Eyelid Syndrome (FES) and pseudotumor cerebri
(PTC) are each associated with OSAS and obesity
- higher IOP is associated with obesity and metabolic syndrome
- the prevalence of glaucoma in patients with OSAS is estimated to be 27%
- multiple studies show that OSAS is the most frequent disorder associated
with NAION
- 25% of patients with OSAS have FES
- 15-40% of patients with PTC have OSAS
c. Macular Degeneration
- risk of advanced AMD higher with diabetes and obesity (5% increase in risk
for every 1kg/m2 increase in BMI)
- AREDS showed that greater BMI doubled risk of Neovascular-AMD
- Waist circumference and diabetes were related to lower macular pigment
optical denisity (MPOD) in the Women’s Health Initiative
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Chous & Richer Obesity Related Eye Disease and Patient Communication
d. Diabetic Retinopathy
- Obesity and weight gain are the primary risk factor for type 2 diabetes
mellitus (T2DM)
- BMI and older age best screen for pre-diabetes (50 million Americans)
- Marked obesity increases risk of retinopathy in T2DM
- 7% of patients with prediabetes have diabetic retinopathy
- You don’t develop diabetic retinopathy if you don’t have diabetes!
- The risk of developing retinal microvascular disease is directly and
continuously related to increasing levels of both insulin resistance and blood
glucose
e. Hypertensive Retinopathy/Venous Occlusive Disease
- The risk of retinal venous occlusion and arterial emboli is 3.8 fold higher for
patients with a BMI > 30
- Risk of CRVO highest in HTN, DM and POAG patients
- Risk of BRVO is highest if the BMI @ 20 years of age > 25 km/m2, preexisting cardiovascular disease, HTN and/or glaucoma
IV. Epidemiology & Definitions of Overweight/Obesity
-
In 2005, 60.5% of Americans were overweight, 23% were obese, and 3% were
morbidly obese
Obesity by Gender: males 24.2% and females 23.5%
Obesity by Age: 18% ages 18-29 and 30% ages 50-59
Obesity by Race: 34% non-hispanic blacks versus 23% non-hispanic whites
Classic Definitions of Overweight & Obesity by Body Mass Index (BMI):
BMI = Weight (pounds)/Height (inches)2 x 703
( kg/m2 )
BMI = Weight (kg)/Height (m) 2
BMI > 25
BMI > 30
BMI > 35
BMI > 40
overweight
obese
severely obese
morbidly obese
Adults
For children & teens, overweight > 85th percentile; obese > 95th percentile:
Other Measures of Obesity:
-Abdominal Adiposity
- Waist circumference > 102 cm (40 inches) in men
- Waist circumference > 88 cm (35 inches) in women
(Slightly higher for non-Europeans)
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Chous & Richer Obesity Related Eye Disease and Patient Communication
- Waist to Hip Ratio
- W/H > 0.8 for women and > 1.0 for men
Increased risk of cardiovascular disease
- Magnetic Resonance Imaging (MRI)
- visceral adipose tissue (VAT) versus subcutaneous adipose tissue (SCAT)
- VAT > SCAT predicted the risk of Metabolic Syndrome in the
Framingham Heart Study
- VAT may explain the ‘paradox’ of the thin patient with type 2 diabetes
V. Biological Rationale for Specific Macronutrients
Dietary Fat
-
Saturated Fat: high intake unquestionably linked to increased cardiovascular risk
& increased inflammation
SFA intake > 10% of calories increases insulin resistance and LDL-C
However, SFA < 7% of total calories has little effect on LDL-C and significantly
decreases protective HDL-C, especially in insulin resistant patients
-
Trans Fats consist of multiple isomers have varying effects on metabolism
trans-10, cis-12 conjugated linoleic acid from hydrogenated oils (animal fat,
margarine, palm oil, coconut oil) significantly increases inflammation and
cardiovascular risk and induces endothelial dysfunction
-
Monounsaturated fatty acids - MUFA (olive oil, nuts avocadoes) decrease
triglycerides, LDL-C and oxidized LDL without decreasing HDL
MUFA decrease soluble inflammatory adhesion molecules and improve
endothelial function
The high arginine content of nuts (especially walnuts) decreases C-reactive
protein levels
-
-
Polyunsaturated fatty acids – PUFA include n-6 and n-3 subtypes
Humans lack the enzymes necessary to produce two essential fatty acids: the n-3
PUFA, -linolenic acid and the n-6 PUFA, linoleic acid
N-3 PUFA tend to decrease inflammation, whereas n-6 PUFA increase
inflammation
The rate of heart disease declines when PUFA are substituted for SFA
The n-3 PUFA, alpha-linolenic acid (found in flax seed, canola, walnut & linseed
oils) is a precursor to the long-chain n-3 fatty acids DHA & EPA but may not be
sufficiently synthesized in optimal quantities, so higher dietary intake of DHA &
EPA are recommended (high concentrations in cold water, oily fish like salmon,
sardines and herring, as well as dietary fish oil)
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Chous & Richer Obesity Related Eye Disease and Patient Communication
-
-
-
-
DHA and EPA decrease plasma triglycerides, FFAs, glucose and insulin, reduce
peripheral insulin resistance, and decrease visceral fat and concomitant production
of inflammatory cytokines
The ratio of n-6 to n-3 PUFA appears to determine effects on lipid and
inflammatory indices, and a 2:1 to 6:1 ratio has been suggested to maximize
cardiovascular benefit; the ratio in the typical American diet is > 15:1
Low fat diets may drive increased consumption of carbohydrate and worsening
insulin resistance
energy-restricted low-fat and low-carbohydrate diets both significantly decreased
biomarkers of inflammation, suggesting that weight loss may be the driving force
underlying reductions in inflammatory biomarkers
modest weight loss (<5%) preferentially decreases visceral fat, resulting in
improved insulin sensitivity and reduction in the risk of type 2 diabetes
Take Home Message on Fats for Patients:
 keep SFA between 7% and 10% of calories
 eliminate trans fats
 increase consumption off MUFA
 increase consumption of n-3 PUFA, including DHA and
EPA
 caloric restriction and moderate physical activity
reduces weight, inflammation & blood pressure
Dietary Carbohydrate & Fiber
-
-
-
-
Refined Carbohydrates and Simple Sugars: high consumption of the simple sugars
-fructose, glucose and sucrose – promotes release of free fatty acids and increased
intravascular oxidative stress
high dietary intake of refined carbohydrates leads to rapid elevation of blood
glucose and insulin, reduces nitric oxide and impairs endothelium-dependent
vasodilation, increasing risk of vascular occlusion
short-term acute hyperglycemia may increase circulating levels of free radicals
and proinflammatory cytokines, such as IL-6, IL-18, and TNF-alpha
by its mass effect, post-prandial hyperglycemia increases cellular glucose uptake
and metabolism within insulin independent tissues, resulting in production of
ROS and vascular insult
The Case for Fiber, Fruits & Vegetables: high fiber, low carbohydrate diet results
in increased insulin sensitivity and reduced inflammation
increased dietary fiber is associated with a significant 6mm/4mm reduction in
blood pressure in hypertensive patients, based on meta-analysis
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Chous & Richer Obesity Related Eye Disease and Patient Communication
-
-
-
-
addition of psyllium fiber and guar gum both reduced BMI, fasting blood glucose
and LDL-C in hypertensive, overweight subjects, but only psyllium resulted in
significant decreases in triglycerides, systolic and diastolic blood pressure
notwithstanding their effects on blood glucose, diets with high intake of fruits and
vegetables are consistently associated with lower cardiovascular risk
The case for alcohol – a derivative of fermentable carbohydrate
moderate intake of all alcoholic beverages (beer, wine and liquor) lowers hs-CRP
and is associated with a lower risk of fatal and nonfatal cardiovascular disease
0.5 to 1 drink per day confers cardiovascular protection primarily by increasing
insulin sensitivity and HDL-C
Resveratrol, a polyphenolic component of red grapes and wine, enhances insulin
sensitivity by activating the enzyme SIRT1 and has been shown to extend lifespan
in invertebrates and mammals
unrelated, super-potent SIRT1 activators have been recently identified that
improve glucose homeostasis in adipose, muscle and liver tissue
Carbohydrate Metabolism: A Link between Diabetes and AMD
a. glycemic index (GI) refers to the incremental area under the blood glucose
response curve of a 50g carbohydrate portion of a test food expressed as a percent
of the response to the same amount of carbohydrate from a standard food (white
bread or glucose) taken by the same subject over a two hour period
b. glycemic load (GL) considers blood glucose response to any given food in light of
the consumed portion size, and is the product of the glycemic index times
consumed carbohydrate in grams, divided by 100.
c. criticisms
- many foods have prolonged glycemic effects (up to ten hours)
- there are wide variations in glycemic response among normal individuals
- GI measurements represent averages amongst normals, not those with decreased
insulin sensitivity, IGT and/or diabetes, so the results may not be generalizable
d. what evidence is there for the utility of GI and/or GL?
- high dietary GL (dGL) increases CRP & triglycerides and lowers HDL-C
- dGL predicts cardiovascular risk in obese patients
- multiple trials show that low GI foods delay hunger and reduce caloric
intake and short term studies suggest that low GL diets result in
significantly more weight loss that high GL diets
- higher dietary GI (dGI) increases risk of advanced AMD ( large drusen,
geographic atrophy, CNVM) and the risk of developing T2DM
- long-term clinical trials are lacking at this time, but basic science strongly
suggests that a lower dGI/dGL decreases inflammation & insulin resistance
- the most comprehensive listing of GI/GL may be accessed at
http://www.ajcn.org/cgi/content/full/76/1/5/T1
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Chous & Richer Obesity Related Eye Disease and Patient Communication
Take Home Message on Carbohydrates & Fiber for Patients
 decrease intake of refined carbohydrate
 reduce & diffuse the glycemic load (smaller, more
frequent meals)
 eat a variety of lower GI/GL fruits & vegetables and
increase intake of dietary fiber to > 25 grams/day
 consider moderate alcohol consumption (1 drink QOD),
preferably red wine
Dietary Protein
-
-
-
both reduced calorie high protein (HP) and reduced calorie high
carbohydrate (HC) diets result in significant weight loss and improve all
components of Metabolic Syndrome (save HDL-C), but HP better decreased
blood pressure and triglycerides
Increasing dietary protein results in heightened satiety and weight loss
possibly by triggering release of satiety enhancing gut hormones, as well as
by increasing thermogenesis
Dietary protein may also, however, promote insulin resistance and
hyperglycemia, as well as contribute to overt kidney disease in the at-risk,
obese population
-
An increasing body of literature suggests that soy protein may have a
beneficial role in obesity
- soy reduces total cholesterol (TC), LDL-C and triglycerides by reducing
intestinal cholesterol absorption and hepatic cholesterol synthesis
- soy appears to reduce production of free fatty acids and improve
peripheral insulin sensitivity
-
Both dietary iron overload (high consumption of red meat) and defects of
iron metabolism (as a function of haptoglobin genotype) are common in DM
Iron overload has been implicated in the pathogenesis of AMD, whereas
haptoglobin genotype has not
-
Take Home Message on Protein for Patients
 increased protein consumption decreases appetite and
assists in weight loss, but these benefits must be weighed
against the possibility of kidney dysfunction and
increased insulin resistance
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Chous & Richer Obesity Related Eye Disease and Patient Communication
 increased consumption of fatty fish and soy protein
preferred
 avoid red meat
VI. Biological Rationale for Specific Micronutrient and Nutraceutical Supplements

reduce inflammation, improve insulin sensitivity, block generation and/or
harmful effects of reactive oxygen species (see below)
VII. Recommendations For Overweight and Obese Patients
Dietary: eat an anti-inflammatory, calorie restricted diet consisting of a variety of low
glycemic load fruits and vegetables, nuts, whole grains and plentiful fiber, favoring cold
water, fatty fish and soy protein, with minimal regular alcohol consumption (red wine)




The so-called “Mediterranean Diet” fulfills all of these criteria
In the Nurses’ Health Study, Mediterranean diet was associated with lower
concentrations of biomarkers of inflammation and endothelial dysfunction
The Lyon Diet Heart Study showed a 70% reduction in heart attack and
unstable angina with the Mediterranean Diet, whereas the European
Prospective Investigation into Cancer and Nutrition study (EPIC) showed an
inverse correlation between greater adherence to a Mediterranean-style diet
and death
Though few studies evaluate the ocular effects of a Mediterranean Diet, one
study showed the lowest incidence of AMD in a rural Italian farming
community. The strong connection between cardiovascular and obesityrelated ocular disease suggests a probable benefit
Supplements: basic and clinical science supports the position that overweight and obese
patients, as well as patients with any degree of insulin resistance, may benefit from
supplementation. However there is no consensus, beyond fish oil supplementation, even in
the integrative medicine community, about what constitutes comprehensive supplementation.
* Fish oil – prevents diabetic arrythmias, MIs, reduces inflammation & triglycerides, and
lowers C reactive protein. Various herbs listed below are also used among different world
cultures where medical care is scant or non-existent.



As for conventional anti-oxidant supplements, although there seems to be
scant evidence of supplement use and ocular outcomes, there are a plethora of
small studies and testimonials suggesting the benefits of various nutrients.
Those at high risk of developing advanced AMD reduced that risk by 25%
with an antioxidant supplement plus zinc, AND…..
Age-Related Eye Disease Study II (AREDS II) will further evaluate the ocular
benefits of lutein, zeaxanthin and n-3 PUFA (accessed 11/28/07 at
http://www.nei.nih.gov/neitrials/viewStudyWeb.aspx?id=120)
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Chous & Richer Obesity Related Eye Disease and Patient Communication
Andrew Weil’s Top 4 Supplement recommendations
•
•
•
•
GTF (glucose tolerance factor) chromium (picolinate)
– 200 mcg – 1000mcg / day
– Helps insulin transport glucose into cells
Alpha Lipoic Acid – 600 – 1200 mg
the R- isoform of ALA (R-ALA) is preferentially distributed to mitochondria
and is unique among anti-oxidants because it is regenerated by glycolytic flux
(a so-called ‘catalytic antioxidant’) rather than being consumed on a
molecule-for-molecule basis by free radical oxidants, making it an ideal
candidate for neutralizing ROS generated by mitochondria
– Helps insulin transport glucose into cells
– Inhibits glycosylated attachment of sugar to protein
– Maintains eye and nerve health (↓peripheral neuropathy)
– Reduces diabetic cataract
• Also Acetyl-L-Carnosine (2 recent studies)- 500 & 1000mg
Magnesium (citrate or taurate) – 400mg
– Insulin production
COQ10- 100 mg
– Maintains cardiac function
– Protects against high dose statins, AMD & Parkinson’s Dz
– 31% drop in blood sugar in 1 study
Bills Sardi’s www.KnowledgeofHealth.com Supplement Recommendations
IP6 phytate* (Rice bran, chia seed powder or flaxseed meal) – binds FE++
Resveratrol – chief source is red wine (www.longevinex.com)
Quercetin – onions, apples - prevents sorbitol BV damage
Taurine – supports cellular membrane structure
Additional Supplements:
•
•
•
Vitamin E (natural d-alpha & mixed isomers)
– Lipid soluble antioxidant; against heart disease & nerve damage
Vitamin C
– 500 mg – 2500 mg serially dosed
– BV health & ↓ insulin resistance, cataract & cancer with multiple MOAs
Flavonoids @70% of vitamin C dose- normalize blood vessel permeability and reduce
hyperglycemia.
– Bilberry (160-320 mg 25% stnd xtract)– Genistein
 blocks protein tyrosine kinase and has been shown to prevent vascular
leakage in an animal model of diabetic retinopathy
– Ginkgo Biloba
– Pycnogenol
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Chous & Richer Obesity Related Eye Disease and Patient Communication


•
•
•
•
•
•
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improves fasting glucose, post-prandial glucose and HbA1c in T2DM
reduces inflammatory biomarkers associated with obesity and appears to
retard vascular leakage in diabetic retinopathy
Lutein (6-20 mg)
Theoretically Protects the macula and circulation i.e AREDS 2 study
Improved visual function (LAST, LAST II and multiple subsequent studies)
Low levels associated with insulin resistance
B Vitamin Complex
– B1 Thiamin or benfotiamine – for carbohydrate metabolism
 benfotiamine is a fat soluble analog of B1
 totally prevented diabetic retinopathy in an animal model by blocking activity
in the polyol, hexosamine, AGE and PKC pathways
– B3 Niacin – to increase HDL cholesterol
– B6 Pyridoxine(s) – for protein metabolism
– Folic acid – for healing; ↓homocysteine
– B12 Methylcarbolamine –for improved nerve cell function
– Biotin – for fatty acid metabolism
Zn/Cu & manganese – immune system, healing; cofactor for SOD
Vanadyl Sulfate – mimics the action of insulin
Selenium – cofactor for GSH peroxidase, a major antioxidant enzyme
GLA/ALA – additional anti-inflammatory essential fatty acids
Curcumin –multiple MOAs, improves response to insulin
Herbs (various ethnic groups and cultures)
•
•
•
•
•
•
•
•
Gymnema Sylvestre (leaf extract from India)
– Improve insulin sensitivity w/o hypoglycemia
– Beta Fast GXR ® & other Indian Herbs (Jambolan, Pterocarpus Marsupium)
Psyllium
Mormordica Extract or Karela (Bitter Lemon- Asia /Ayurvedic) -Assists glucose
pathways in liver – plant insulin like peptide
Fenugreek seed extract – stimulates pancreatic function and improves glucose
tolerance
Konjac Mannon
Nopal (Prickly pear cactus- Mexico)
Cinnamon- ancient greek / latin writings
Banaba (Philippines)
-others, garlic, ginseng, dandelion, burdock
Take Home Message on Supplements
 The science is emerging and not definitive.
 Omega III fatty acid consumption can save patients with diabetes from
sudden death.
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Chous & Richer Obesity Related Eye Disease and Patient Communication
 Lipoic acid, the subject of European Meta-analyses is an effective adjunct
for peripheral polyneuropathy, beyond Neurotin® and antidepressants
which are effective in perhaps 50 to 60% of patients.
 Complex DM metabolic dysfunction requires multiple nutrients – but there
is no current consensus on which are most important.
 There is a new formulation for Diabetic Eye Health: B&L Ocuvite® DF
that contains lipoic acid, genistein and various other nutrients.
Physical Activity: get 30 minutes of moderate exercise most (at least 5) days of the week



Exercise with or without weight loss results in substantial reductions in total
and abdominal adiposity
both the Finnish Diabetes Study and the Diabetes Prevention Program
demonstrated that increased physical activity significantly lowers the risk of
type 2 diabetes in high-risk patients (58% reduction in the DPP over 3 years)
exercise training significantly promotes SIRT1 activity that improves insulin
sensitivity and may also extend human lifespan
Communication:
1. Set an effective tone for communication by asking about your patient’s comfort
discussing weight status, by being careful to distinguish between the weight problem
and the person, and by focusing on the specific health risks (AMD, diabetes and
diabetes-related eye disease. cataract, etc.)
2. Assess the patient’s motivation to lose weight and current dietary and exercise status
3. Build a partnership by helping the patient set just a few realistic goals (e.g. lose 7%
of body weight, walk 2000 steps daily, lower blood pressure by 10/5 mm Hg) and
methods to achieve them (adopt the Mediterranean Diet, buy a pedometer, etc.)



physicians face numerous barriers to effectively counseling patients on weight
loss, including how, when and with whom to have these discussions
language is power - obese patients find the terms “fat” and “obese” highly
derogatory in their conversations with health care providers, overwhelmingly
preferring the terms “weight,” “excess weight,” or “high BMI”
the vast majority of patients who are overweight (84%) and obese (27%)
believe they need to lose weight, but a minority had discussed weight loss
with their current physicians; the same survey found that what these patients
most wanted from their PCPs is dietary advice, help setting weight loss goals,
and exercise recommendations
VIII. Conclusion (FIGURE 2)
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Chous & Richer Obesity Related Eye Disease and Patient Communication
Battling ocular (and systemic complications) of obesity is analogous to keeping an
overflowing bathtub from ruining the bathroom floor (figure 2).
1. “Turn Off the Faucet” by reducing dietary calories, increasing physical activity,
controlling blood glucose and blood pressure
2. “Bail Excess Water Out of the Tub” by losing weight, particularly visceral
adiposity that drives abnormal glucose metabolism, hypertension, production of
reactive oxygen species and inflammation
3. “Mop Up the Floor” with an anti-inflammatory diet, as well as synergistic antioxidants and micronutrients that broadly target the metabolic abnormalities
associated with obesity





How to Prevent the Overflowing Bathtub
From Ruining the Bathroom Floor
Caloric Restriction
Increase Energy
Expenditure
Blood Glucose Control
Blood Pressure Control
CPAP for OSAS
TURN OFF the FAUCET


 Weight
Loss

AntiInflammatory
Diet
Targeted Antioxidants
Targeted
micronutrients
BAIL the BATHTUB
MOP UP the FLOOR
- caloric restriction
- exercise
- pharmacotherapy (sibutramine, orlistat, rimonabant) & bariatric surgery
References: 172 removed to accommodate AAO document size submission guidelines
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