Pick a disease, any disease. If you told a patient that a healthy diet and regular exercise habits diminished their risk of acquiring that disease (or decreased the likelihood of that disease worsening if you already had it) they would likely believe it. Being “healthy” always sounds like a good idea, and it should! It has been consistently demonstrated that healthy choices made on the part of the patient positively impact overall health.
Since this is the case, as healthcare practitioners we should remember to “prescribe” healthy lifestyle modifications for every patient. With the aging of the global population, the rise of sedentary lifestyles, climbing obesity rates of developed countries, and the resulting prevalence of many diseases, both ocular and systemic, healthcare professionals can help a great deal by being advocates for healthy lifestyle choices.1
The following is a non-exhaustive summary of some interesting lifestyle risks for important ocular conditions along with specific recommendations that can be made to patients for the prevention and mitigation of these diseases.
Cataract formation becomes ubiquitous in old age and it is thus the leading cause of blindness and the second leading cause of visual impairment worldwide.2 Alcohol consumption and tobacco use have been shown to increase the rate of cataract formation while the regular use of sunglasses to protect against UV (ultraviolet) radiation due to sunlight exposure decreases risk.3,4,5
Diet is also important here, with antioxidants like lutein and zeaxanthin and adherence to a vegetarian diet protecting against cataract formation and high blood sugar in both diabetic and nondiabetic patients contributing to the condition.6,7,8 Exercise has also been demonstrated to act positively against this process, with lower BMI (body mass index), greater physical activity, and greater cardiorespiratory fitness associated with lower risk.9 Inversely, greater inactivity is frequently associated with greater cataract risk.10
Glaucoma is the leading cause of irreversible vision loss worldwide, with primary open angle glaucoma (POAG) being the most common variety overall and the one that we optometrists normally treat.11 It again has several lifestyle influences, with perhaps the most notable of late being the use of marijuana. While cannabis, like glaucoma medications, reduces intraocular pressure (IOP), it does so transiently, requiring several repeated doses, and also lowers perfusion to an already compromised optic nerve head; these factors mean that marijuana, unfortunately, is not a suitable treatment for glaucoma at this time.12
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Regular aerobic exercise, cessation of cigarette smoking, limiting caffeine intake, and drinking red wine have, however, been shown to lower IOP and the risk of progression in patients with Primary Open Angle Glaucoma.13 Interestingly, one study demonstrated that mindfulness meditation in patients with POAG reduced IOP and stress biomarkers and positively influenced gene expression, leading the authors to recommend this practice as an adjunct therapy for those with POAG.14
Age-related maculopathy (ARM) is an important disease to address in our elderly population as it is the most common cause of blindness in developed countries for those over 60 years of age.15 Smoking is a common risk factor for both the development and progression of ARM and alcohol consumption is moderately associated with increased ARM risk.16,17 Exercise, again, helps here and exerts a protective effect on the progression from atrophic (dry) to exudative (wet) ARM.18 Meanwhile, overall abdominal obesity increases the risk of progression.19
The adoption of a Mediterranean diet has also been shown to be associated with reduced risk of progression to advanced ARM and, as before, a reduction in a patient's dietary glycemic index has also been shown to reduce the risk for ARM in both diabetic and nondiabetic patients.20,21 The original Age-Related Eye Disease Study (AREDS) demonstrated that high levels of antioxidants (including beta-carotene) and zinc significantly reduced the risk of advanced ARM and its associated vision loss in those at high risk of advanced ARM.22 AREDS 2 showed that lutein and zeaxanthin together could safely and effectively replace beta-carotene in the original AREDS formulation, which, in supplement form, caused increased incidence of lung cancer in smokers.23
Myopia prevalence is projected to increase to 50% of the world’s population by 2050 with pathologically high myopia making up a significant portion.24 This is due, in part, to the increasing amount of excessive near work activities in the world’s children, both in the educational system and in leisurely electronics use.25 More time outdoors has been linked with lower myopic progression while hyperglycemic diets and hyperinsulinemia, particularly during periods of ocular growth, have been shown to contribute to myopic progression by promoting cell proliferation and growth in ocular (among many others) tissues.26,27 Exercise has also been directly associated with lower axial length.28
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In conclusion, we must treat our patients with corrective measures such as spectacles and contact lenses, medications, and surgery, but we also need to recommend proven, healthy lifestyle changes as adjunct measures for optimal outcomes. We do not regularly save lives, but every day we work to preserve our patients' quality of life and improve their performance in their daily activities. As stewards of ocular and systemic health then, we must constantly remind everyone how to better take care of themselves.
- Mather M, Jacobsen LA, Pollard KM. Population Bulletin: Aging in the United States. Population Reference Bureau 2015;70.
- Song P, Wang H, Theodoratou E, Chan KY, Rudan I. The national and subnational prevalence of cataract and cataract blindness in China: a systematic review and meta-analysis. J Glob Health 2018;8:01804.
- Hiratsuka Y, Ono K, Murakami A. Alcohol Use and Cataract. Current Drug Abuse Reviews 2009;2:226-229.
- Raju P, George R, Ramesh SV, Arvind H, Baskaran M, Vijaya L. Influence of tobacco use on cataract development. Br J Ophthalmol 2006;90:1374-1377.
- Roberts J. Ultraviolet Radiation as a Risk Factor for Cataract and Macular Degeneration. Eye & Contact Lens: Science & Clinical Practice 2011;37:246-249.
- Thiagarajan R, Manikandan R. Antioxidants and cataract. Free Radical Research 2013;47:337-345.
- Appleby PN, Allen NE, Key TJ. Diet, vegetarianism, and cataract risk. Am J Clin Nutr 2011;93:1128–35.
- Kumar CM, Seet E, Eke T, Dhatariya K, Joshi GP. Glycaemic control during cataract surgery under loco-regional anaesthesia: a growing problem and we are none the wiser. British Journal of Anaesthesia 2016;117:687–91.
- Williams PT. Prospective Epidemiological Cohort Study of Reduced Risk for Incident Cataract with Vigorous Physical Activity and Cardiorespiratory Fitness during a 7-Year Follow-up. Invest Ophthalmol Vis Sci. 2009;50:95–100.
- Selin JZ, Orsini N, Lindblad BE, Wolk A. Long-Term Physical Activity and Risk of Age-Related Cataract: A Population-Based Prospective Study of Male and Female Cohorts. Ophthalmology 2015;122:274-280.
- Tham Y, Li X, Wong TY, Quigley HA, Aung T, Cheng C. Global Prevalence of Glaucoma and Projections of Glaucoma Burden through 2040: A Systematic Review and Meta-Analysis. Ophthalmology 2014;121:2081-2090.
- Novack GD. Cannabinoids for treatment of glaucoma. Curr Opin Ophthalmol 2016;27:146–150.
- Tsai JC. Influencing ocular blood flow in glaucoma patients: the cardiovascular system and healthy lifestyle choices. Can J Ophthalmol 2008;43:347–50.
- Dada T, Mittal D, Mohanty K, Faiq MA, Bhat MA, Yadav RK, Sihota R, Sidhu T, Velpandian T, Kalaivani M, Pandey RM, Gao Y, Sabel BA, Dada R. Mindfulness Meditation Reduces Intraocular Pressure, Lowers Stress Biomarkers and Modulates Gene Expression in Glaucoma: A Randomized Controlled Trial. J Glaucoma 2018;27:1061–1067.
- Wong WL, Su X, Li X, Cheung CMG, Klein R, Cheng C, Wong TY. Global prevalence of age-related macular degeneration and disease burden projection for 2020 and 2040: a systematic review and meta-analysis. Lancet Glob Health 2014;2:e106–16.
- Velilla S, García-Medina JJ, García-Layana A, Dolz-Marco R, Pons-Vázquez S, Pinazo-Durán MD, Gómez-Ulla F, Arévalo JF, Díaz-Llopis M, Gallego-Pinazo R. Smoking and Age-Related Macular Degeneration: Review and Update. Journal of Ophthalmology 2013.
- Adams MKM, Chong EW, Williamson E, Aung KZ, Makeyeva GA, Giles GG, English DR, Hopper J, Guymer RH, Baird PN, Robman LD, Simpson JA. 20/20—Alcohol and Age-related Macular Degeneration: The Melbourne Collaborative Cohort Study. Am J Epidemiol. 2012;176(4):289–298.
- Knudtson MD, Klein R, Klein BEK. Physical activity and the 15-year cumulative incidence of age-related macular degeneration: the Beaver Dam Eye Study. Br J Ophthalmol 2006;90:1461–1463.
- Seddon JM, Cote J, Davis N, Rosner B. Progression of Age-Related Macular Degeneration: Association With Body Mass Index, Waist Circumference, and Waist-Hip Ratio. Arch Ophthalmol 2003;121:785-792.
- Merle BMJ, Silver RE, Rosner B, Seddon JM. Adherence to a Mediterranean diet, genetic susceptibility, and progression to advanced macular degeneration: a prospective cohort study. Am J Clin Nutr 2015;102:1196–206.
- Chiu C, Milton RC, Gensler G, Taylor A. Association between dietary glycemic index and age-related macular degeneration in nondiabetic participants in the Age-Related Eye Disease Study. Am J Clin Nutr 2007;86:180–8. The Age-Related Eye Disease Study Research Group.
- The Age-Related Eye Disease Study (AREDS): Design Implications AREDS Report No. 1. Control Clin Trials 1999;20(6):573–600.
- Chew EY, Clemons T, SanGiovanni JP, Danis R, Domalpally A, McBee W, Sperduto R, Ferris FL, the AREDS2 Research Group. The Age-Related Eye Disease Study 2 (AREDS2): Study Design and Baseline Characteristics (AREDS2 Report Number 1). Ophthalmology 2012;119(11):2282–2289.
- Holden BA, Fricke TR, Wilson DA, Jong M, Naidoo KS, Sankaridurg P, Wong TY, Naduvilath TJ, Resnikoff S. Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050. Ophthalmology 2016;123:1036-1042.
- Goldschmidt E, Jacobsen N. Genetic and Environmental effects on myopia development and progression. Eye 2014;28:126–133.
- Rose KA, Morgan IG, Smith W, Burlutsky G, Mitchell P, Saw S. Myopia, Lifestyle, and Schooling in Students of Chinese Ethnicity in Singapore and Sydney. Arch Ophthalmol. 2008;126(4):527-530.
- Cordain L, Eades MR, Eades MD. Hyperinsulinemic diseases of civilization: more than just Syndrome X. Comparative Biochemistry and Physiology Part A 2003;136:95–112.
- Read SA, Collins MJ. The short-term influence of exercise on axial length and intraocular pressure. Eye 2011;25:767–774.