Findings from Optometrists’ Practices in Advising about Lifestyle Study

Abstract

Significance:

Lifestyle influences eye health and other chronic diseases. All healthcare providers, not just primary care physicians, should have the necessary information and training to advise and refer patients on lifestyle in order to take advantage of opportunities to provide such advice.

Purpose:

The extent to which optometrists offer lifestyle advice to their patients is largely unknown. The Optometrists’ Practices in Advising about Lifestyle (OPAL) Study aimed to examine lifestyle advice that optometrists offer, to whom such advice is offered, and reasons for not offering this advice.

Methods:

We developed and administered a mail-in survey to 140 optometrists in Western New York.

Results:

Five surveys were returned due to death, retirement and relocation. Of the 135 remaining eligible participants, forty-six of the optometrists contacted responded to our survey; however only 42 (31%) provided signed consent forms. Of these, more than 93% report offering advice on smoking, dietary supplements and diet, and >59% on physical activity and alcohol use. Eighty-three percent offer advice only to those with unhealthy behaviors or certain conditions. Most advice consisted of mentioning the lifestyle factor’s influence on eye or overall health. Reasons for not offering advice included lack of knowledge or training or the belief that advice would not change behaviors.

Conclusions:

Optometrists reported offering advice primarily to those with unhealthy lifestyle behaviors or pre-existing health conditions. Future studies should address low response rates, include non-physician healthcare providers in addition to optometrists, and should also examine patients’ perceptions and understanding of the advice offered to better understand whether this advice is received as the provider envisioned.

Lifestyle, including diet,¹ physical activity,^{2, 3} smoking,^{4, 5} and dietary supplement use,⁶ are thought to be related to eye health and other chronic diseases. Previous work shows that physicians can influence lifestyle behaviors,^7–9 and this is likely true for other healthcare providers. Individuals may sometimes visit other health providers (e.g., optometrists, dentists, etc.) more frequently than physicians.¹⁰ Healthcare providers have the opportunity to offer lifestyle advice to patients who might not normally seek care from a physician.

Optometrists are well placed to advise on lifestyle practices to individuals who may not typically seek the care of a physician but need a prescription for glasses or contact lenses. Few studies have characterized lifestyle advice offered to patients by optometrists^11–18 and most focused primarily on advice about smoking.^11–13 Only a few studies examined advice offered regarding diet and focused primarily on supplement use.^14,15,18,19

The current American Optometric Association’s (AOA) guidelines²⁰ state that eye doctors should ask about patients’ smoking status and counsel them on smoking cessation but offers no specific advice on the format with which that counseling should be delivered. Further, the guidelines report that there is evidence that advising patients to limit their alcohol intake, partake in physical activity and refrain from smoking can prevent eye damage and that optometrists should advise their patients accordingly. These guidelines also state that the expert consensus is that, “Eye doctors should be aware of their patients’ dietary and supplementation practices and counsel them on good nutrition for eye health”.¹⁰ Other AOA guidelines, targeted to specific conditions, contain specific references to the benefits of the consumption of green leafy vegetables and antioxidant supplementation for prevention of age-related macular degeneration²¹ and the recommendation that all patients with diabetic retinopathy be provided advice on maintaining glycemic control, smoking cessation and healthy lifestyle including physical activity and diet.²² The AOA does not give specific guidelines on lifestyle advice that should be offered to patients with dry eye,²³ glaucoma²⁴ or cataract.²⁵

We conducted a study in Western New York to assess the lifestyle advice offered by optometrists and determined whether this advice (if given) is given to all patients or only to those patients with certain conditions (e.g., diabetes). We queried optometrists for their reasons for not offering lifestyle advice to identify barriers and potential opportunities to increase the extent to which optometrists do so.

METHODS

This study conforms to the tenets of the Declaration of Helsinki. The study protocol was approved by the University at Buffalo’s Health Sciences Institutional Review Board; written, informed consent was obtained from all participants.

Recruitment and Participation

The Optometrists’ Practices in Advising about Lifestyle (OPAL) study, surveyed optometrists practicing in the Western New York (WNY) region, specifically Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans and Wyoming Counties. There were 195 optometrists registered in these counties in February 2013.²⁶ New York State does not provide names of healthcare professionals. Consequently, we used internet search engines, telephone books and insurance listings to locate optometrists in the region. Our methods were as rigorous, or even more so, as those used by patients in search of an optometrist.

In an effort to obtain additional study participants, the President of the Western New York Society of Optometrists (WNYSO), which represents optometrists practicing in WNY region, sent an email to all members encouraging them to fill out our survey. We also recruited participants at two of the WNYSO’s meetings by explaining the study to attendees and offering copies of the survey to those who could not recall receiving one in the mail. There were 67 optometrists belonging to the WNYSO²⁷ at this time and approximately 25 of them attended each of these meetings.

First Mailing

We ascertained that there were 195 registered optometrists residing in the study area through the New York State Department of Education’s website,²⁶ however, this website does not identify optometrists by name or address. We mailed study materials (cover letters, consent forms, surveys and return envelopes with postage) to 140 optometrists practicing in the WNY region for whom we were able to obtain contact information. As an incentive to complete and return the survey quickly, those optometrists who returned a completed survey by a certain date were eligible for a lottery drawing. Twenty-four optometrists returned the completed survey by this date. We were unable to find addresses for four surveys which were returned to us unopened. Figure 1 illustrates the study recruitment process and enrollment.

Figure 1.

Participant recruitment process and enrollment in the Optometrists’ Practices in Advising about Lifestyle Study.

Second Mailing

Optometrists that did not respond to the first mailing were hand delivered (n=68) or mailed (n=44) a second survey. We attempted to contact these optometrists by telephone to remind them to complete the survey. After the second deliveries and mailings, we received eight additional completed surveys, one survey that did not have a signed consent form, two unopened surveys for which we could not find a valid address and one survey in which the optometrist stated that they had retired. We determined, by telephone, that one optometrist was no longer practicing in the WNY region, two optometrists had retired, and one was deceased.

Third Mailing

Due to low response rate, we mailed bright yellow, hand-addressed envelopes containing reminders to all optometrists who did not respond to the two previous mailings. This mailing informed optometrists that it was not too late to be included in the study. We provided information on obtaining replacement study materials and a return envelope but not an additional survey. We received 10 more completed surveys, three surveys without signed consent forms, and two unopened envelopes for which we could not find a valid address.

We removed the 5 individuals who were no longer in the study area, retired, or deceased from our recruitment pool resulting in a total eligible of 135 participants. We analyzed 42 of the 46 surveys that were returned because the consent forms were missing from 4 participants. This brought our response rate to 31%.

Survey

We did not find any previously validated comprehensive surveys of lifestyle advice administered to optometrists therefore we designed a self-administered mail-in survey that queried for general information about the participant and the advice they, as optometrists, offer on the following lifestyle factors: smoking, alcohol consumption, physical activity, healthy eating, dietary supplements and specific foods and supplements (see Appendix, available at [LWW insert link]). For each lifestyle factor, participants were asked to whom they give advice, what type of advice they offer (when offered) and why they do not provide advice (if no advice was offered). For each one of these questions, response choices were listed, and a space was provided in which optometrists could write in an answer that was not listed. We chose these lifestyle factors because they have been shown in the literature to influence either vision or chronic health conditions. We chose a paper-based survey because we were unable to obtain email addresses for the optometrists in the study, and, since the optometrist might not be near a computer when opening the study envelope, we felt they would be more inclined to fill out the paper-based survey and insert it into the envelope on the spot than to later remember to visit a website on a computer. Additionally, studies comparing response rates on modes of survey administration found they were similar, and sometimes better, on paper-based surveys compared to web-based surveys^28–30. This survey was pilot tested in 10 optometrists at Casco Bay Eyecare in Maine and modified for any ambiguities prior to its administration in our study sample.

Statistical Analyses

Descriptive statistics were used to describe the study sample and to illustrate quantitatively the advice being offered by participants to patients. These statistics include proportions and absolute numbers of optometrists’ responses to the categorical questions in our survey and, because our continuous data was not normally distributed, we report medians and interquartile ranges (IQR) for these variables. Analyses were conducted using SAS version 9.3 analytical software.

RESULTS

Participant Characteristics

Study participants were split almost evenly between sexes (48% male vs 52% female). The median age was 47.5 (IQR 36 – 57) years and the median time participants had practiced optometry was 20 (IQR 9.75 – 29.25) years. Most participants were either the owner or co-owner of the practice in which they work (36%) or employed in an ophthalmology practice (26%). The median number of patients optometrists saw per week was 66.5 patients (IQR 50 −100) and about half spent less than 20 (IQR 15 – 25) minutes with each patient. The median amount of time optometrists spent providing lifestyle advice per patient was 4.5 (IQR 2–5) minutes (Table 1).

Table 1.

Characteristics of Optometrists Participating in the Optometrists’ Practices in Advising about Lifestyle Study (N=42).

Characteristic	n (%)
Sex
Male	20 (48)
Female	22 (52)
Type of Practice
Owner or Co-owner in Private Practice	15 (36)
Employed in Someone else’s private practice	8 (19)
Commercial practice	7 (17)
Ophthalmology practice	11 (26)
Other	1 (2)
	median (IQR)
Age (in years)	47.5 (36 – 57)
Years in Practice	20 (9.75 – 29.25)
Patients seen per week	66.5 (50 – 100)
Time spent with each patient (in minutes)	20 (15 – 25)
Time spent providing lifestyle advice (in minutes per patient)	4.5 (2 – 5)
Percentage of patients that are white*	90 (75 – 95)
Percentage of patients that are over 65 years of age	37.5 (25 – 60)
Percentage of patients that have diabetes	20 (10 – 25)
Percentage of patients that visit more than once*	70 (45 – 80)

^*missing data for one participant

Information Optometrists Report Collecting on Participant’s Health

Most participants collected information on their patients’ smoking status, diabetes status and medication use (98%). Fewer asked about alcohol consumption, dietary supplement use and blood pressure (60–81%). Less than 25% gathered information about their patients’ overall dietary intake, physical activity level, weight and height. (Table 2).

Table 2.

Table of Health-Related Information Collected from Optometrists Participating in the Optometrists’ Practices in Advising about Lifestyle Study (N=42).

Type of Information	Participants obtaining information from patients on this factor n (%)
Smoking status	41 (98)
Diabetes status	41 (98)
Medication use	41 (98)
Alcohol Use	34 (81)
Dietary Supplements	33 (79)
Blood pressure	25 (60)
Overall Diet Pattern/Dietary intake	10 (24)
Physical Activity	9 (21)
Weight and height	6 (14)

Patients to Whom Lifestyle Advice is Offered

Of the optometrists who offered advice to at least some patients, 12% reported that they give at least some lifestyle advice to all their patients and 83% reported they only offered advice to certain patients. Only two 5% of optometrists reported they offered no advice because their work organization has other healthcare providers who are responsible for offering this advice, they did not have the proper training to offer this advice and their advice will do little to change a patient’s lifestyle.

The lifestyle factors that optometrists advised on most were smoking and factors related to nutrition and least on alcohol consumption and physical activity. (Table 3) Seventy-four percent of optometrists reported offering advice on smoking to patients who smoke and to those with dry eye or age-related macular degeneration (74% for each of these categories). Nutritional advice, including advice on healthy diet, dietary supplements or specific foods and supplements, was provided to those patients that had age-related macular degeneration (81%, 79% and 79%, respectively) followed by dry eye (43%, 71% and 64%, respectively), diabetes (64%, 19% and 36%, respectively) and diabetic retinopathy (64%, 19% and 40%, respectively).

Table 3.

Patients to whom lifestyle advice is offered by optometrists participating in the Optometrists’ Practices in Advising about Lifestyle in Western New York Study (N=42).

	Lifestyle Factor
Patients to whom advice is offered	Any Advice	Smoking	Alcohol Consumption	Physical Activity	Healthy Diet	Dietary Supplements	Specific Foods and Supplements
	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)
All	5 (12)	4 (10)	3 (7)	3 (7)	6 (14)	3 (7)	4 (10)
Only Certain Patients‡	35 (83)	36 (86)	22 (52)	29 (69)	34 (81)	36 (86)	36 (86)
None	2 (5)	2 (5)	17 (40)	10 (24)	2 (5)	3 (7)	2 (5)
When offered to only certain patients, advice was offered to those reporting
Undesirable levels of this lifestyle factor	na†	31 (74)	20 (48)	15 (36)	15 (36)	15 (36)	14 (33)
Dry Eye	na†	31 (74)	5 (12)	2 (5)	18 (43)	30 (71)	27 (64)
Glaucoma	na†	6 (14)	2 (5)	3 (7)	4 (10)	3 (7)	2 (5)
Cataract	na†	13 (31)	4 (10)	3 (7)	7 (17)	7 (17)	4 (10)
Age-related Macular Degeneration	na†	31 (74)	6 (14)	6 (14)	34 (81)	33 (79)	33 (79)
Diabetic Retinopathy	na†	14 (33)	10 (24)	18 (42)	27 (64)	8 (19)	17 (40)
Diabetes	na†	16 (38)	12 (29)	22 (52)	27 (64)	8 (19)	15 (36)
Cardiovascular Disease	na†	15 (36)	7 (17)	15 (36)	17 (40)	2 (5)	11 (26)
Other Conditions	na†	2 (5)	3 (7)	1 (2)	1 (2)	0 (0)	0 (0)

^†na = not asked

^‡Participants that answered all and certain conditions at the same time were counted as giving advice to all patients.

Lifestyle advice was most often offered to patients with the following eye conditions: dry eye, age-related macular degeneration and diabetic retinopathy. Optometrists in the study offered some advice to patients with chronic diseases such as diabetes and cardiovascular disease, for example, 64% of optometrists offered advice about healthy diet to patients with diabetes and 40% to those with cardiovascular disease.

Type of Advice Offered to Patients

Among the 95% of optometrists that stated that they advise patients about smoking, 100% mentioned that smoking can affect vision and 78% that smoking can affect their overall health. (Table 4) Specific advice given was to see their physician about smoking (38%), to attend a smoking cessation program (10%), provision of a video or pamphlet (8%), and to use nicotine replacement therapy (8%).

Table 4.

Types of advice offered to patients by optometrists participating in the Optometrists’ Practice in Advising about Lifestyle Study (N=40).

	Lifestyle Factor
	Smoking	Alcohol Consumption	Physical Activity	Healthy Diet	Dietary Supplements	Specific Foods and Supplements
Number of participants offering advice on this lifestyle factor to any patients	40	25	32	40	39	40
Type of Advice Offered*	n (%)§	n (%)§	n (%)§	n (%)§	n (%)§	n (%)§
Mentions that lifestyle factor can affect their vision	40 (100)	20 (80)	20 (63)	37 (95)	31 (79)	na
Mentions that lifestyle factor can affect their overall health	31 (78)	24 (96)	28 (88)	34 (89)	37 (95)	na
Offers a pamphlet and/or has them watch a video	3 (8)	1 (4)	1 (3)	6 (16)	7 (18)	na
Suggests nicotine replacement therapy (i.e., patch, gum)	3 (8)	na	na	na	na	na
Advises patient to see their physician about lifestyle factor	15 (38)	8 (32)	9 (28)	17 (45)	14 (36)	na
Refers patient to a program that addresses lifestyle factor	4 (10)	2 (8)	1 (3)	2 (5)	na	na
Other	1 (3)	0 (0)	2 (6)	2 (5)	6 (15)	na

^*categories are not mutually exclusive

^§percentage of number of participating optometrists offering advice on this lifestyle factor

Advice on alcohol consumption followed a pattern similar to that on smoking; most optometrists mention to their patients that alcohol can affect their vision (80%) or health (96%). Reported advice offered about alcohol consumption included referrals to a doctor (32%), referrals them to alcohol cessation or counseling programs (8%) and information via a pamphlet or video (4%).

Optometrists who reported advising their patients about physical activity told them that it could affect their vision and/or health (63% and 88%, respectively) while 28% percent counsel patients to see their physician and less than 5% offer a pamphlet/video or refer patients to a physical activity program.

Optometrists who advise their patients on healthy diet or dietary supplements tell them that these nutritional factors can influence vision (95% and 89%, respectively) and/or health (79% and 95%, respectively). Of the 40 optometrists advising about a healthy diet and the 39 that provide advice on dietary supplements, 45% and 36%, respectively, advise patients to see their physician, dietician or nutritionist about their diet or supplement use.

Reasons for Not Giving Advice

Although, all but two (5%) of participants gave at least some advice to patients, two did not give advice on smoking, 17 did not advise on alcohol consumption, 10 did not advise on physical activity and few on healthy diets, diet supplementation or specific foods and supplements (2, 3, and 2, respectively). The reasons most cited for not giving advice were lack of time, training or knowledge and lack of belief that their advice would result in the patient changing their behavior. Less cited reasons for not providing advice were that patients were not receptive to such advice and a lack of evidence that the lifestyle factor affected eye health (Table 5).

Table 5.

Reasons given for not giving specific lifestyle advice by optometrists participating in the Optometrists’ Practice in Advising about Lifestyle Study (N=42).

	Lifestyle Factor
	Smoking	Alcohol Consumption	Physical Activity	Healthy Diet	Dietary Supplements	Specific Foods and Supplements
Number of participants that do not offer advice on this lifestyle factor	2	17	10	2	3	2
Reason for not offering advice*	n (%)†	n (%)†	n (%)†	n (%)†	n (%)†	n (%)†
Lack of time during the appointment	1 (50)	3 (18)	1 (10)	0 (0)	0 (0)	0 (0)
Lack of proper training/knowledge to offer lifestyle factor advice	1 (50)	7 (41)	4 (40)	1 (50)	2 (67)	1 (50)
Patients are not receptive to advice about this lifestyle factor	0 (0)	2 (12)	3 (30)	0 (0)	0 (0)	0 (0)
My advice will do little to change a patient’s behavior on this lifestyle factor	1 (50)	3 (18)	4 (40)	1 (50)	1 (33)	1 (50)
There is no scientific evidence that this lifestyle factor influences eye health	0 (0)	1 (6)	0 (0)	0 (0)	1 (33)	1 (50)
Other	1 (50)	2(12)	1 (10)	1 (50)	1 (33)	1 (50)

^*categories are not mutually exclusive

^†percentage of number of participants not offering advice on this lifestyle factor

DISCUSSION

This study provides data on a comprehensive survey designed to assess the type and extent of lifestyle advice offered to patients by optometrists. The majority (>93%) of our participants offer advice on lifestyle factors however the majority (83%) also reported that they offer advice only to certain patients. Advice offered was comprised of telling patients that the lifestyle factor influences eye health or health overall. The most frequent explanations for not offering advice were lack of knowledge or training or that the advice would do little to change a patient’s behavior.

Our study found that the majority (40 out of 42) of optometrists asked patients about their smoking habits and advised patients on this behavior. Other studies also observed that between 33% and 70% of optometrists asked patients about their smoking, and only one study found that more than 40% of participants advised smokers to quit smoking.^{16, 17, 31} We found that all 95% of participants in our study advised patients who smoked that smoking can affect vison and 74% advised them that it can affect overall health. Some participants counseled patients who smoked to, see a physician about smoking (36%), attend a smoking cessation program (10%), watch a video or read a pamphlet (7%), or to use nicotine replacement therapy (7%). This is different than the findings from a study of optometrists and optometry students (N=29) in Canada which found that, although the optometrists were well educated on the relationship between smoking and eye disease, not one optometrist claimed to have assisted even a single patient to quit smoking,¹³ In that study, participants asserted that they did not counsel patients on smoking cessation because they lacked training, had no financial incentive to do so, were not familiar with local smoking cessation programs, or did not have time to counsel patients on smoking cessation.¹³ Another, larger, Canadian study (N=288) revealed that, while most optometrists knew that they should ask about their patients’ smoking practices, only 16% did so and, only 26% of those who did, offered smoking cessation advice to those patients who smoked.¹¹ Our results also differ from an online survey of optometrists in Australia in which less than 50% of the 283 participating eye doctors said they made it a practice to ask their patients about their smoking habits and, of those, most (80.2%) claimed to offer advice to smokers on cessation¹⁸ It is possible that differences in cultural norms around smoking between countries is responsible for the differences found.

Most optometrists in the Canadian study (72%) claimed that lack of training was the greatest obstacle to offering counseling on smoking, but many (48%) expressed interest in obtaining this training.¹¹ We did not inquire as to whether or not optometrists in our study were interested in obtaining this training.

Although most of the optometrists in our study offer patients advice about smoking, some did not similarly advise patients on alcohol use and physical activity. Perhaps due to the fact that little is known about the association between physical activity, and, although heavy alcohol use has been found to be associated with eye disease, some studies have found that moderate alcohol use may actually help protect against some eye diseases.³² Optometrists participating in our study provided reasons similar to the Canadian studies on smoking for not offering advice on alcohol use and physical activity, i.e., lack of time or training. In contrast to the Canadian studies, optometrists in our study also reported that patients were not receptive to healthy lifestyle advice or that the advice would not change a patient’s behaviors. It is difficult to draw conclusions as to why optometrists in our study did not provide advice on smoking, diet and dietary supplements due to the small number of optometrists reporting not giving advice on these factors.

A study in the U.S. found that optometrists and ophthalmologists felt their advice would be futile and were concerned about losing patients by offering smoking cessation advice.¹² We did not ask if optometrists felt that offering advice would result in a loss of patients; however, we provided space for participants to write reasons for not providing advice to patients and none cited fear of losing patients. The Australian study found that the reasons for not offering advice about smoking included a lack of time, that patients were already aware that they shouldn’t smoke and that this topic was too personal.¹⁸

A survey of 135 optometrists and ophthalmologists in Michigan observed that the majority (~75%) advised their patients with age-related macular degeneration to take dietary supplements.¹⁴ In Wisconsin, optometrists were also queried about the advice they offer on dietary supplements and eating leafy greens (a source of lutein and zeaxanthin, carotenoids that have been shown to be inversely associated with age-related macular degeneration³³). This study found that optometrists, in general, felt that they were adequately informed about the benefits of lutein and zeaxanthin and that most advised their patients to eat leafy greens and take lutein and zeaxanthin supplements (85.8% and 86.6%, respectively).¹⁵ In our study, most optometrists offer advice on diet (95%) and dietary supplements (93%) to patients with age-related macular degeneration suggesting that they too are well informed on the benefits of lutein and zeaxanthin for this disease, potentially due to the results of the Age-Related Eye Disease Study (AREDS) and AREDS II trials. The original AREDS trial found that supplementation with high-dose antioxidants may protect against AMD,³⁴ and the subsequent AREDS II trial found that use of lutein and zeaxanthin in lieu of beta-carotene was a safer and similarly effective treatment.³⁵ Studies conducted outside the U.S. also found that a high percentage of optometrists offered patients advice on diet (range: from 29% to 67%) and dietary supplements (range: 34% to 93%).^16–18

Our study was limited by low response rate and small sample size. Studies conducted in Michigan,¹⁴ Wisconsin,¹⁵ and throughout the U.S.³⁰ also suffered from low response (20.6%, 42.3% and 21.25% respectively). Studies conducted in the UK, Sweden and Australia did not have substantially higher response rates (range: 6.7% to 40.3%).^16–18 After two mailings we suspected that our envelope, clearly marked as coming from the University at Buffalo, was perceived as junk mail and may not have even made it into some optometrists’ hands. We then mailed brightly colored, hand addressed envelopes resembling a greeting card and received a greater response with this third mailing than with the second. Techniques that are more likely to get surveys into the healthcare providers’ hands directly, prior to office triage, may increase response rates and should be pursued in future studies.

The optometrists in our study were similar in age (median of 47.5 years) to those responding to a 2012 national survey of optometrists by the AOA (mean 46 years).³⁶ The median number of patients our participants saw per week was 66.5 not very different than the 60 per week claimed in the national survey. However, the percentage of female optometrists in our study varied from the national study (52% and 39% respectively) as did the percentage of patients over 65 that the optometrists reported seeing (median of 37.5% and means ranging from 17% to 21%).³⁶ It is possible that self-selection bias exists in our study since only 31% of the optometrists we attempted to contact responded to our survey. We have no reason to believe that our study sample is not representative of all optometrists in western New York; however, optometrists that responded may have been more likely to offer advice than those that did not.

Current AOA guidelines¹⁰ provide recommendations to optometrists on giving advice on smoking, alcohol use, diet and physical activity. However, on average, the participants in our study reported being in practice for 20 years when filling out the survey and they may not have been trained in providing advice on lifestyle factors when they attended optometry school. Although optometrists practicing in New York State must complete 36 continuing education hours every 3 years,³⁷ it is possible that the optometrists in our study completed these hours, and any additional continuing education, in areas that did not include providing advice on these lifestyle factors.

Knowledge of advice offered by eye care providers, and reasons they may not offer advice on certain lifestyle factors, can help identify opportunities for improvement in lifestyle counseling among eye care professionals. Such advice can be valuable as lifestyle behaviors such as smoking,³⁸ physical activity,³⁹ and diet⁴⁰ are risk factors for most chronic diseases. Further, patients may not receive this advice elsewhere or may benefit from being offered such advice from multiple healthcare providers.

We found that optometrists offer lifestyle advice to their patients especially on smoking, diet and dietary supplements and to those patients with AMD, dry eye, diabetic retinopathy and diabetes. Public health professionals are encouraged to ensure all healthcare providers, not just primary care physicians, have the necessary information and training to advise and refer patients on matters related to lifestyle (e.g., dietary counseling or alcohol cessation programs). Future studies should include other healthcare providers (e.g., dentists or podiatrists) to understand the types of lifestyle advice offered by other healthcare providers that people visit to in lieu of, or in addition to, physicians. Patients’ perceptions and understanding of the advice offered to them by healthcare professionals should also be investigated to better understand whether this advice is received as the provider envisioned. Finally, the effectiveness of this advice should be measured by whether or not it actually results in the lifestyle changes intended.