Obesity is the fastest-growing epidemic in the United States, according to the U.S. Assistant Surgeon General.1 The prevalence of obesity in the United States was 20.9% in 2001, a 5.6% increase from a year earlier and a 74% increase from 1991.2 With an estimated U.S. population of 296.5 million, that means about 62 million adults in the United States were obese in 2001.3

A national health objective for the year 2010 is to reduce the pre­va­lence of obesity among adults to less than 15%.4 However, statistics indicate that the situation is getting worse rather than improving.4 Globally, more than 1 billion adults are overweight, and at least 300 million of them are obese.5 With an estimated world population of 6.5 billion, that means 15.4% are overweight, and 4.6% are obese.6

Obesity affects ocular as well as systemic health. Given our role in the patients well being, we cannot turn a blind eye to obese patients.

 
Measures of Obesity

Obesity is defined as excess body fat relative to lean body mass.7 We most commonly measure and diagnose obesity by body mass index (BMI). BMI is a simple calculation of weight (kg) divided by height (m2). Using pounds and inches, BMI equals weight divided by [height (inches)]2 and then multiply the quotient by 703.

Adults ages 20 years and older are considered underweight if BMI is less than 18.5, normal if BMI is 18.5 to 24.9, overweight if BMI is 25 to 29.9 and obese if BMI is 30 or more. BMI for children and teens (ages 2 to 20) is plotted on age- and gender-specific growth charts.

Another measure of obesity: abdominal obesity. This represents the additional weight an individual gains in the abdominal region. There are two ways to determine abdominal obesity:

Waist circumference. A normal waist circumference is less than 40 inches for men and less than 35 inches for women. A waist circumference that exceeds these normal values is a health risk.8-10

Waist-to-hip ratio. This measure compares the waist measurement at the smaller circumference of the natural waist, usually just above the navel, to the hip measurement at the widest part of the buttocks. Individuals who have apple- shaped bodies (more weight around the waist) face more health risks than those whose bodies are pear-shaped (more weight around the hips).11

Any person whose waist is bigger than his or her hips is at high risk for obesity-related complications (see Waist-to-Hip Ratio Health Risk Factors, below).

Waist-to-Hip Ratio
Health Risk Factors 76,77

Health Risk                Male                Female

Low                             0.95 or             0.80 or
                                     less                less

Moderate                   0.96 to             0.81 to
                                     1.00                  0.85

High                            1.00+                0.85+

Given the myriad health problems associated with overweight and obese in­dividuals, these patients have a significant economic impact on the United States. This includes direct and indirect costs. Direct costs include preventive, diagnostic, and treatment services related to obesity. Indirect costs include morbidity costs, the value of lost income due to decreased productivity, restricted activity, absenteeism and bed days, and mortality costs, meaning the value of future income lost by premature death. Direct medical ex­penses attributed to overweight and obese individuals accounted for 9.1% of total U.S. medical expenditures in 1998 and may have reached as high as $78.5 billion.12

 

Systemic Problems

Obesity is a major contributor to chronic disease and disability.

Diabetes is the most common comorbidity associated with obesity.13 Diabetes is so closely associated with obesity that Shape Up America, a nonprofit organization that raises public awareness about obesity, coined the term Diabesity, which refers to the causal connection between obesity and type 2 diabetes.14 According to Shape Up America, 97% of all cases of type 2 diabetes are due to excessive weight. Obese people are five times more likely to develop diabetes than smokers, and they are at an even higher risk than that due to the effects of 20 years of aging.15

Obesity also is a well-known independent risk factor for heart disease, which itself is the most common cause of mortality in developed countries.16,17 Other common complications of obesity are genitourinary complications, obesity hypoventilation syndrome, sleep apnea, acid reflux, osteo­arthri­tis, gout, hepatic disease, various forms of cancer, depression, dementia, periodontitis, gallstones, kidney stones, various dermatological conditions and premature death.18-40

Metabolic syndrome is a combination of several of the entities mentioned above. It is characterized by central obesity, dyslipidemia, raised blood pressure and insulin resistance.41

 
Visual Impact

In addition to these systemic conditions, obesity can result in serious consequences to patients ocular health and may cause significant visual disabilities. Ocular complications of obesity include:

Diabetic retinopathy. Besides its link to diabetes, obesity is a risk factor for the pathogenesis of diabetic retinopathy and other micro­vascular abnormalities associated with diabetes.42-45 Specifically, high BMI and a high waist-to-hip ratio are significant risk factors for the development of diabetic retinopathy.

Obesity is a risk factor for the pathogenesis of diabetic retinopathy.


Age-related macular degeneration. Several studies link obesity to the development and progression of AMD. One study found that obese men are more than twice as likely to develop dry AMD than men whose BMI is normal.46 Another found an association between BMI outside the normal range and early macular degeneration.47 Additional research found that lutein and zeaxanthin are re­duced in obese individuals, possibly due to decreased dietary intake and/or competition between the retina and adipose tissue for the uptake of these pigments.48

Obesity increases the risk of AMD due to the physiologic changes that occur with obe­­sity.49 These include increased oxidative stress, changes in the lipo­protein profile and increased inflammation. Such changes result in increased destruction and decreased circulatory delivery of lutein and zeaxanthin to the macula of the eye.49

Overall obesity and abdominal obesity increase the risk that patients in the early or intermediate stages of macular degeneration will progress to advanced AMD.50 However, increased physical activity tends to decrease the risk of AMD progression.

Cataracts. Numerous studies cite obesity as a risk factor for cataract development, particularly cortical and posterior subcapsular cata­racts.51-56 In one study, for example, patients whose BMI was 30kg/m2 had a 36% higher risk of any type of cataract than those whose BMI was less than 23kg/m2. The association was strongest for posterior subcapsular cataract (PSC), possibly due to glucose intolerance and insulin resistance, even in the absence of clinical diabetes.51

Analysis of data from more than 20,000 patients in the Physicians Health Study found that BMI as well as height and abdominal adiposity are independent risk factors for cataract, suggesting that weight loss and reduction of central obesity would lessen the incidence and costs of cataract.53 And, the Barbados Eye Study found that high prevalence of cortical opacities was re­lated to diabetes, hypertension and abdominal obesity, which also are common in this and black populations. Interventions to modify these risk factors, especially in high-risk populations, may help stem cataract-induced vision loss .54

Numerous studies cite obesity as a risk factor for cataract development.

Elevated intraocular pressure. Although there is no association between glaucoma and obesity, there is an association between elevated IOP, an important risk factor for glaucoma, and obesity.57-60 Insulin resistance may account for this association.61 In one study, patients who had metabolic syndrome tended to have higher IOPs than patients who did not; IOP was even higher in patients with metabolic syndrome than in obese patients without metabolic syndrome.61

Obesity can also affect IOP measurements. IOP in obese patients was falsely elevated by an average 4.7mm Hg when measured with the Goldmann applanation tonometer vs. a Perkins hand-held tonometer, one study found.62 These patients had an average BMI of 34. By contrast, patients whose BMI was normal had a mean difference of 0.33mm Hg.

One possible explanation for these findings: Obese patients may hold their breath as they strain to get their faces into the slit-lamp biomicroscope for Goldmann tonometry. This compresses the thorax, causing a subsequent increase in venous pressure and a transitory elevation of IOP. Hand-held tonom­etry in obese patients may help avoid a false diagnosis of elevated IOP. (See Accommodate the Obese Patient, below.)


Accommodate the Obese Patient

Many obese patients are effectively disabled and require special considerations when they visit an optometric office. Some ways to accommodate obese patients:

Make sure your office is wheelchair accessible. This includes ramps or elevators and doors that are wide enough even for wide wheelchairs to pass through.

Have proper seating. A loveseat or a couch in your waiting area will make ambulatory obese patients more comfortable than if they had to squeeze between the arm rests of a standard-sized chair. Also, have an examination chair with armrests that tilt back or can be removed if the patient cannot fit between the armrests.

Use hand-held instruments. It is difficult for extremely obese patients to lean forward and put their chin in a chin rest. A hand-held tonometer and slit lamp biomicroscope can be very useful for these patients.

When you must use a standard slit lamp, stand the patient up, lean him or her forward, and use the examination chair as buttocks support. This allows for easier positioning of the obese patient at the slit lamp.75

Obese patients receive a glauco­ma diagnosis more frequently than patients whose BMI is normal. Two reasons for this: Obese patients are more likely to have a higher IOP, and as mentioned above, their measured IOP is likely to be falsely higher when measured by Goldmann tonometry.63 However, ocular hypertension may be a more accurate diagnosis for many obese patients whose IOP is elevated.59 Consider obesity-related ocular hypertension in the differential diagnosis when evaluating obese patients for glaucoma.64

Floppy eyelid syndrome (FES). The recent literature and several well-known textbooks list obesity as a risk factor for floppy lid syndrome.65-67 FES usually affects middle-aged obese men.65 There is some association between FES and ob­struct­ive sleep apnea, which is also associated with obesity.65

Pseudotumor cerebri. Pseudotumor cerebri, also known as be­nign intracranial hypertension, has long been associated with obesity in females.68-70 Although pseu­do­tumor cerebri rarely occurs among males, obesity does not appear to be a risk factor for males who do develop the condition.71

This patient with pseudotumor cerebri has an edematous optic nerve.


Exophthalmos. Obese patients are more likely than non-obese patients to develop exophthalmos that resembles Graves orbito­pa­thy.72 Researchers found differences in Hertel exophthalmometry in obese patients as well as an enlarged medial rectus muscle by echography. Standard values for exophthalmometry and orbital echography may have to be adapted for obese individuals, they concluded. Any time you suspect that bilateral exophthalmos is Graves orbitopathy, include a differential diagnosis of obesity as the etiology.


The Optometrists Role

Given the association of obesity with blinding eye diseases, you must educate patients about the complications that can result from obesity. To do so, you need to:

Identify which patients require education and counseling. A diagnosis of obesity can be made according to the patients BMI. O.D.s who work in multi-disciplinary settings have access to this information. However, we normally do not collect those vital signs as part of our examination.

Some possible solutions: Acquire a scale, and measure each patients height and weight; in­clude height and weight questions in your patient history (keep in mind that the reliability of the patients answers can be questionable); or visually assess the patients waist-to-hip ratio.

Educate the patient about the ocular manifestations of obesity. Make sure the patient understands that you are concerned about his or her ocular health and not just appearance. Patients may be more concerned about their vision than their systemic health, so education may motivate them to pursue a healthier lifestyle and lose weight.

Offer ideas about how to lose weight. One possible resource: the National Weight Control Registry (www.nwcr.ws), a database of people who have self-reported a weight loss of 30 pounds or more and kept it off for at least a year. Participants answer researchers questions about how they achieved their weight loss. The researchers who maintain the NWCR found that 89% changed their diets and increased physical activity (10% used diet modification only and 1% used activity only).73

Because obesity generally results from too much caloric intake combined with too little physical activity, treatment of obesity should address both causes. The three basic approaches for the prevention and treatment of obesity are to reduce the dietary energy intake, increase the energy spent on activity, and reduce inactivity.74 One way to help obese patients is to offer specific suggestions on how to lose weight. (See Prescription for Weight Loss, below).


Prescription for Weight Loss 78

Nutrition

                Set regular times to eat. Eat three meals and no
                  more than two snacks daily.
                Limit saturated and trans fats.
                Increase daily intake of fruits and vegetables to at
                 least five portions; aim for seven to nine portions.
               Fiber can increase the feeling of fullness. Aim for
                 two to three servings of whole grain food per day.
               Limit sweetened beverages. Drink water or nonfat or 1% milk.
               For personalized dietary information, visit 
                 www.mypyramid.gov.

Increased physical activity  

               If you drive to work or stores, park far from the
                  door and walk. 
                If you take public transportation, get off a stop
                  early and walk.
               Take the stairs whenever possible.
                Display your exercise prescription in a visible 
                  place.
                Purchase a pedometer and aim for 10,000 steps 
                  per day.
               Consider strength training for 20 minutes two to
                 three times per week.
               Exercise with friends or a group so youll be motivated.

Reduced inactivity

               Limit computer game time and non-essential
                  computer work.
               Cook and clean up rather than going out to eat.
               Do your own landscaping, and mow the lawn
                  with a push mower.
               If possible, walk or bike to and from work, and
                  walk during your lunch break.
                Do something physical when watching TV or 
                   reading, such as using a treadmill or exercise bike.


Document this discussion and your recommendations in the patients record. Follow up on this advice when the patient returns for subsequent appointments.

Seek additional help. Consider referring the patient to a dietician or general practitioner for more detailed education and follow-up care. Other resources that may be helpful: an exercise physiologist, physical therapist and bariatric surgeon (for gastric bypass surgery).

As a primary health-care pro­vid­er, you must know how obesity affects your patients ocular health. It is equally important to educate overweight and obese patients about healthier lifestyle choices, as these choices will reduce their risk for co-morbid ocular and systemic conditions.


Dr. Bohlman practices at the Mountain Home VA Medical Center in Johnson City, Tenn., and lectures on obesity.

 

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