Best 6 Ways to Keep Diabetic Retinopathy Under Control
A top expert recommends an easy-to-remember alphabet of lifestyle changes to help safeguard your vision.
If you have diabetes or are prediabetes, mind your A-B-C-D-E and S to preserve your vision. That’s the memorable advice of Judy E. Kim, MD, president of the American Society of Retina Specialists and a retina specialist at the Medical College of Wisconsin in Milwaukee.
From tracking your A) A1C, B) blood pressure, and C) cholesterol, to D) disciplined eating, E) exercise, and saying no to S) smoking, Dr. Kim’s six-letter alphabet of practices can help stop or slow the damage created by the vision-robbing diabetic retinopathy (DR).
In the United States, millions of people are already at risk. Almost one-third of those over age 40 who’ve been diagnosed with the so-called sugar disease have or will develop diabetic retinopathy, a common complication of diabetes that remains a leading cause of blindness worldwide.
The flipside is far more positive: An estimated 95 percent of them can mitigate its onset and effects through early detection, rigorous monitoring, and the lifestyle changes that Kim promotes.
Diabetic retinopathy results from years of excess blood sugar, or hyperglycemia. According to the federal Centers for Disease Control and Prevention (CDC), more than 37 million people (that’s 1 in 10 Americans) have diabetes, which impairs the body’s ability to utilize glucose as energy.
Individuals with diabetes don’t make enough or are resistant to insulin, the hormone that allows glucose to enter cells and be used for fuel. When glucose remains in the bloodstream, it causes damage to blood vessels as it circulates through the body, including the blood vessels in the eye.
These increasingly fragile vessels can leak into the interior eye. While some minor bleeds can resolve on their own or respond to laser treatments, excessive bleeding and advanced diabetic retinopathy can seriously and irreversibly impair sight.
“Both people with type 1 diabetes (the autoimmune disease that often occurs early in life) and people with type 2 diabetes (which usually strikes later in life) can develop this complication, as can those with gestational diabetes (which occurs during pregnancy),” says Kim.
She adds: “We categorize the severity of DR based on the number of microaneurysms (ballooning of blood vessel walls) that occur; how much leakage results; how abnormal the blood vessels are, and how much the vision is affected. The risk rises based on the duration of the diabetes and the degree to which the blood sugar levels are elevated.”
Once these vessels are damaged or closed off, Kim says, “There’s no way to make them come alive again.”
Advancing diabetic retinopathy can trigger additional complications, from diabetic macular edema (swelling in the retina), to retinal hemorrhage (heavy bleeding), to retinal detachment (where portions of the retina pull away from the wall of the interior eye).
The worst damage can be stemmed or stopped, Kim says, if people successfully master the following A-B-C-D-E and S early in the process.
Included in an annual complete blood count (CBC), A1C pinpoints the percentage of hemoglobin that is glycosylated (meaning it has sugar attached).
“A1C is the number one thing I tell people to track because it affects everything else downstream,” Kim says. “As the A1C increases, it not only leads to vision problems but can seriously affect the heart, kidney, and other systems,”
High levels of sugar-saturated hemoglobin (the red-colored protein that transports oxygen throughout the body) put an undue burden on the hormone insulin, which enables the body to convert and utilize sugar as energy. As the numbers rise, insulin becomes less efficient. Eventually, the strain becomes too great and the body stops producing the critical hormone.
The CDC sets the normal A1C level at below 5.7 percent. A level between 5.7 and 6.4 indicates prediabetes. Once the percentage exceeds 6.5, diabetes mellitus is diagnosed. Any elevation in blood sugar puts an individual at heightened risk for diabetic retinopathy.
“If an individual’s A1C is greater than 7.5, they should speak to their healthcare provider and if it’s above 8.0, they should be under the care of a diabetes specialist,” Kim says. In her view: “People with diabetic retinopathy should check their A1C at least every three months, either with a laboratory study at the doctor’s office or lab or by checking blood sugars at home.”
Of course, the frequency of testing can vary with each individual and that person’s A1C level, which is why people conducting their own tests should do so while staying in close contact with their physician.
Home test kits are widely available from major pharmacies, including CVS and Walgreens, and from online retailers such as Costco and Amazon without a prescription. In addition, some pharmacies provide real-time finger-prick A1C testing, occasionally accompanied by pharmacist advice. Kits selling for an average of $50 deliver results in about five minutes. Check with your insurance provider to see if the cost is covered. (Be aware that several studies have shown that some home A1C test results may not be as accurate as those obtained in a doctor’s office or laboratory setting.)
“Remember,” Kim says, “diabetes is a vascular disease; that is, it affects the circulatory system.”
High blood pressure or hypertension is twice as common among individuals with diabetes as it is within the general population. Heightened pressure strains vessels and can lead to aneurysms, bulging, or bleeding.
By contrast, carefully managing blood pressure can lower diabetic retinopathy risk, as confirmed in clinical trials such as the large population-based study published in the March 2020 issue of PLoS One.
Kim suggests that those with diabetic retinopathy track blood pressure with home monitors. The small, easy-to-operate devices are available at pharmacies and online for between $40 and $75. Some drug stores also offer free on-site blood pressure checks.
Healthy blood pressure shouldn’t exceed 120 for systolic (the first of the two numerals that represent blood pressure, this measures the pressure exerted by the heartbeat itself) and 80 for diastolic (the second number, which measures the force on artery walls between beats, as vessels relax). The National Institutes of Health on Aging defines “elevated” blood pressure as a systolic reading of between 120 and 129 with a diastolic pressure of less than 80. “High” blood pressure kicks in when systolic climbs to 130 or beyond and diastolic exceeds 80.
“I typically recommend checking blood pressure several times a week, or any time someone is feeling ill,” Kim says. “And, again, if the numbers are abnormal and continue to increase, a visit to the healthcare provider is appropriate.”
Like high blood pressure, the buildup of plaque — vessel-clogging cholesterol deposits — imperils blood vessels. “A high cholesterol reading can cause atherosclerosis, or narrowing of the vessels, which can also affect the eyes,” says Kim.
Cholesterol comprises LDL or low-density lipoproteins and HDL or high-density lipoproteins. LDL is blamed for cholesterol build-up and deposits, which can break off and send debris to the heart, causing a heart attack; to the brain, leading to stroke; or to the retinal artery, precipitating a sudden loss of vision.
To complicate things, insulin resistance (the hallmark of type 2 diabetes) can lower the body’s production of "good" HDL cholesterol levels while raising triglycerides (a kind of fat found in the blood) as well as "bad” LDL cholesterol.
While lifestyle changes can make a difference, many doctors prefer to use statin drugs. These include atorvastatin (Lipitor), fluvastatin (Lescol), pravastatin (Pravachol), rosuvastatin (Crestor), and simvastatin (Zocor).
According to a study published in the April 2019 issue of JAMA Ophthalmology, these medications potentially diminished the need for diabetic retinopathy treatment, rendering study participants 36 percent less likely to progress to the condition’s advanced stage while diminishing the risk of retinal detachment. The drugs are believed to dampen the inflammation that worsens diabetic retinopathy. Even if LDL is normal, these drugs may have an additional benefit.
The U.S. Food and Drug Administration (FDA) has warned that, ironically, statins themselves can hike glycosylated hemoglobin levels. The agency stopped short of requiring warning labels, contending that the cardiovascular good that they do outweighs the small chance of them leading to a rise in blood sugar.
The annual blood panel performed for a regular physical exam measures total cholesterol levels, as well as HDL, LDL, and triglyceride levels. In between, if your doctor recommends it, you can use at-home tests sold at pharmacies, usually without a prescription. Prices generally begin at about $20 and include a finger-stick lancet to draw a drop of blood and a test strip to display the results. Some devices include electronic screens.
A few caveats: Insurance generally covers in-office tests; few providers reimburse for home kits. Also, results delivered by home medical tests in general can vary according to the particular product and the way it’s used; they shouldn’t be considered substitutes for doctor-supervised monitoring and care.
One of the best ways to control diabetes and diabetic retinopathy is with disciplined eating emphasizing fresh vegetables, fatty cold-water fish, nuts rich in omega-3 fatty acids, and abundant soluble fiber.
Oatmeal and oat bran provide high-fiber nutrition, while mackerel, salmon, and responsibly sourced tuna are rich in beneficial omega-3 fats, as are nuts such as almonds and walnuts.
Kim also reminds people with diabetes or prediabetes to consider the way in which foods, consumed at regular times, help maintain healthy blood sugar levels.
The American Diabetes Association “plate” approach to a diabetes-friendly diet calls for filling half a meal plate with no-starch vegetables such as carrots, spinach, and tomatoes; a quarter of the plate with lean proteins (preferably fish); and the last quarter plate with whole grains.
“I always encourage my patients to keep moving,” says Kim.
Activity improves insulin sensitivity, manages weight, moderates blood pressure, controls harmful LDL cholesterol, and strengthens muscles and bones.
“A 10 percent weight loss can have a huge effect on diabetes as well as on diabetic retinopathy,” Kim says. “Simply walking 30 minutes three times a week can make a major difference, even when walks are divided into 10-minute increments.”
Drugs now being researched may eventually help control metabolic syndrome, the combination of obesity, high blood pressure, and high triglycerides that contributes to diabetes and diabetic retinopathy. In the meantime, Kim reminds those with diabetic retinopathy that “any activity” improves overall health.
It’s long been known that smoking worsens many ailments, but a meta-analysis of existing studies, published in the August 2018 issue of Endocrine, found that smokers with type 1 diabetes face a “significantly higher” diabetic retinopathy risk. The same was not found for type 2 diabetes smokers, but the habit poses many other threats for them.
Among her own patients, Kim has found that giving up cigarettes yielded “the single greatest effect” on eye health.
Kim says she believes that anyone who rigorously follows these tips can tame diabetic retinopathy’s sneaky threat to vision. “With early detection and by adopting good prevention habits,” she says, “blindness from diabetes can be virtually eliminated in everyone who is at risk, while overall health can be significantly improved.”
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