Recommending Nutraceuticals Is a State of Mind

One way to help ensure compliance is to offer therapies in your own office.

By Robert L. Davis OD, FAAO

Patients are focused on health and wellness today more than ever before. Many of our patients are interested in vitamins and nutraceuticals to promote eye health and general well-being, although there are some skeptics who question their effectiveness. With their interest in leading healthier lifestyles, vitamin users are more likely to exercise, to eat healthy, and to visit their medical and eye care practitioners regularly.1

Some eye care providers are reluctant to sell nutraceuticals and vitamins in their practices. This leads to the question: Is there a difference between selling or recommending nutraceuticals and vitamins to your patients and dispensing spectacles and contact lenses to them? I would argue that there is not. In fact, offering these products can be a great benefit for many of our patients.

Practitioners who sell health care products such as nutraceuticals, eye scrubs, and eye care solutions believe that offering their preferred brands in the office can help patients choose those specific, recommended products, rather than searching through the maze of options on drug store shelves, which may have varied levels of therapeutic benefit. Directing patients to these products helps to ensure that they receive the ingredients and dosages we prescribe.

Critics of in-office sales are uncomfortable with the supposed conflict of interest that is encountered when practitioners profit by selling products they recommend to patients. But if these products are not offered by the practice, there is a risk that patients will buy and consume something that is not effective or is contraindicated. Also, there is the convenience factor to consider. In a recent national study, three out of four Americans said that they would prefer to fill their therapeutic prescriptions in a doctor’s office instead of having to go to a pharmacy.2 Unfortunately, most people are not given that choice.

Office-based dispensing guarantees that patients have the recommended or prescribed therapeutic products in hand before leaving the office. Going to a pharmacy, patients always run the risk of selecting the wrong product. Patients appreciate the convenience of being able to purchase their supplements at the doctor’s office. It spares them an extra trip and a long wait at the pharmacy.

This practice also enhances compliance by ensuring that prescriptions and recommendations get filled. One study found that new prescriptions for common maintenance medications went unfilled from 20% to as much as 30% of the time.3 When patients leave with the prescription already filled, we eliminate the possibility that they will postpone filling the prescription, lose the prescription, or simply forget about it.

Stocking and selling these products can also be a financial win for the doctor. Forces such as declining insurance reimbursements and the emergence of consumer-driven health care are pushing many doctors to explore new ways to improve the patient experience and to find new revenue sources.

The first step in moving toward offering nutraceuticals is to understand the science behind them. In order to recommend and sell these products, you must have conviction that they work and offer benefit to patients. Your recommendations are then motivated by your knowledge of the benefits of the nutraceuticals. This is what I meant by my title above, that offering nutraceuticals requires the right frame of mind. This article aims to outline some of the purported benefits of selected nutraceuticals and vitamins, and to provide an introduction to those who have not yet begun offering these products to their patients.

AVOIDING CONFUSION

Many patients shop around pharmacies looking for specific supplements, self-diagnosing and treating a problem they may or may not have. Recently a patient told me that she had picked up a nutriceuticals for age-related macular degeneration (AMD) because she had heard it was good for preserving vision. I asked the patient what type of medicines she was taking, and she told me that her primary care provider had prescribed blood thinners. I told the patient to stop taking the nutraceuticals until we had checked with her primary care provider because it might influence the activity of her prescribed medication.

Another example of potential for confusion is the dry eye disease supplement omega-3 fatty acids. These fatty acids are available in multiple formulations, typically either as triglyceride or ethyl ester. But when patients look for these supplements in a pharmacy, grocery store, or health food store, without proper instruction they tend to purchase whichever bottle is most appealing. This is not exactly the best approach to buying a product meant to promote health.

Patients should take nutritional supplements under the supervision of a doctor, and this can best be accomplished by offering the recommended supplements in the office. These in-office supplements guarantee quality control that can be monitored over time.

UNDERSTANDING ATTITUDES

Understanding consumers’ attitudes about nutraceuticals purchasing habits can help in the dialogues we have with our patients. There is a significant generation gap among those who use vitamins. About one-third of people who are 18 to 29 years old say they regularly take vitamins or mineral supplements. Vitamin use increases among older patients, reaching higher than 50% in the 50-to-64 age group and continuing upward to 68% for seniors. Vitamin use also rises with education: 43% of those with no more than a high school education say they take vitamins regularly, and the percentage steadily rises with college experience. Vitamin use also increases with income and is more prevalent among women (Table).4

With a good understanding of the demographics of your patients who take nutraceuticals and supplements, you have a better chance to identify those who would benefit from education on their proper use and indications. Sharing with patients some of the information in the following section can help steer them in the right direction regarding supplement choice and utilization.

POTENTIAL BENEFITS

Much research has been conducted on the benefits and risks of vitamins and nutraceuticals. The following only scratches the surface, but it can be a starting point for learning to incorporate nutraceuticals recommendations into your eye care practice.

Antioxidants and other important nutrients have been shown to improve night vision and contrast sensitivity. Studies suggest that certain nutriceuticals may reduce the risk of AMD, glaucoma, cataracts, and dry eye disease.5

The plant compounds called bioflavonoids may protect against cataracts and macular degeneration.6 They help ocular tissues to fabricate rhodopsin, improving night vision. Tea, red wine, citrus fruits, bilberries, blueberries, cherries, legumes, and soy products are excellent food sources for this vitamin.

Lutein and zeaxanthin are yellow pigments that protect our eyes against phototoxic blue light.7 With low levels of these pigments, the absorption of these harmful wavelengths is diminished, and patients may be at higher risk for cataracts and AMD. Spinach, kale, turnip greens, collard greens, squash, eggs, and yellow, orange, and red fruits are sources of these nutrients.

Omega-3 fatty acids may help prevent AMD and dry eye disease.8,9 They are said to help maintain the integrity of the nervous system, improve the immune system, and provide nutrients to cellular components. Research has demonstrated that these compounds are necessary for proper visual development and retinal function. Coldwater fish such as salmon, mackerel, and herring; freshly ground flaxseeds; and walnuts are good examples of food sources.

Zinc plays a role in helping transport vitamin A from the liver to the retina to produce melanin. Zinc is highly concentrated in the vascular tissues of the retina and choroid.10 Oysters and red meat are high in zinc, but vegetarians can get zinc from soy, beans, and grains.

Vitamin A is essential for the fabrication of rhodopsin, which helps the eye adjust to changes of lighting and night vision.11 It is necessary for regeneration of the epithelial tissue of the eye and for wound healing. Vitamin A also neutralizes free radicals in tissues that have low oxygen concentrations, such as the crystalline lens, thus helping to prevent cataracts. Foods rich in vitamin A include spinach, cantaloupe, and sweet potato.

Vitamin C is an antioxidant that strengthens the walls of blood vessels, reducing their permeability. It also helps in removing free radicals in the crystalline lens, delaying cataract formation. When taken with other essential nutrients, vitamin C it has been shown to slow the progression of AMD and reduce intraocular pressure.12 Vitamin C occurs mainly in fruits such as oranges and leafy green vegetables such as kale, collard greens, and Brussels sprouts.

Vitamin E is another antioxidant that protects the cells from free radicals that can break down healthy tissues, as in cataract formation. Vitamin E has been shown to lower the risk of AMD development when combined with carotenoids and vitamin C.12 Vitamin E can be found in nuts, wheat germ, and sweet potatoes.

Selenium protects from oxidative stress that leads to free radical formation. It is another antioxidant that helps to delay the formation of cataracts and removes free radicals in the macula.13 Selenium is important to the body’s absorption of vitamin E as well. Fish, poultry, lean meat, wheat germ, brown rice, pumpkin seeds, and garlic are all great sources.

CONCLUSION

Protecting patients’ vision and providing them with the best ocular health assessment, including information on therapeutic outcomes, are the most important missions of our occupation. The therapies we offer—whether devices such as contact lenses or spectacles, medications for disease, nutraceuticals, eye drops, contact lens solutions, or accessory products such as eye scrubs—are essential parts of our therapeutic armaments.

Assuring that patients receive only the best therapeutic suggestions can help to improve their outcomes. Offering those best therapeutic options for sale in our practices helps to ensure that these therapies are actually implemented. It only makes sense that selling the best nutraceuticals and accessory products to our patients is no different from dispensing the best spectacles or contact lenses to them.

1. Dickinson A, MacKay D. Health habits and other characteristics of dietary supplement users: a review. Nutr J. 2014;13:14. DOI: 10.1186/1475-2891-13-14

2. Patient Attitudes toward Point-of-Care Medication Dispensing in a Primary Care Office Setting. July 19-22, 2007 by Opinion Research Corporation on behalf of Purkinje. www.purkinje.com.

3. Fischer MA, Stedman MR, Lii J, et al. Primary medication non-adherence: analysis of 195,930 electronic prescriptions. J Gen Intern Med. 2010;25(4):284-290.

4. Swift A. Half of Americans Take Vitamins Regularly. December 19, 2013. Gallup website. http://www.gallup.com/poll/166541/half-americans-vitamins-regularly.aspx. Accessed January 4, 2017.

5. Hosseini HRJ, Mosallaei M, Kalameh ZA. The effect of nutrition and supplements on ocular health. Iran Red Crescent Med J. 2009;11(1):10-17

6. Majumdar S, Srirangam R. Potential of the bioflavonoids in the prevention/treatment of ocular disorders. J Pharm Pharmacol. 2010;62(8):951-965.

7. Hobbs RP, Bernstein PS. Nutrient supplementation for age-related macular degeneration, cataract, and dry eye. J Ophthalmic Vis Res. 2014;9(4):487-493.

8. Parodi MB, Zucchiatti I, Cicinelli MV, et al. Nutritional supplementation in age-related macular degeneration. Retina. 2016;36(6):1119-1125.

9. Epitropoulos AT, Donnenfeld ED, Shah ZA, et al. Effect of oral re-esterified omega-3 nutritional supplementation on dry eyes. Cornea. 2016;35(9):1185-1191.

10. Kiser PD, Golczak MK, Palczewski K. Chemistry of the retinoid (visual) cycle. Chem Rev. 2014;114(1):194-232.

11. Palczewski K. Chemistry and biology of the initial steps in vision: the Friedenwald lecture. Invest Ophthalmol Vis Sci. 2014;55(10):6651-6672.

12. Age-Related Eye Disease Study Research Group. A Randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins c and e, beta carotene, and zinc for age-related macular degeneration and vision loss. Arch Ophthalmol. 2001. 119.10 (2001)

13. Brenneisen P, Steinbrenner H, Sies H. Trace elements and human health. Selenium, oxidative stress, and health aspects. Review. Mol Aspects Med. 2005;

Robert L Davis, OD, FAAO
• Practices in Oak Lawn, Illinois, and is director of the Contact Lens Clinic at Davis EyeCare
• (708) 636-0600; eyemanage@aol.com
• Financial disclosure: consultant to ZeaVision