Decide where nutritional supplementation falls among your practice
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As the popularity of nutritional supplements increases, ODs are faced with new clinical practice issues. Should you recommend supplements to your patients? Should you dispense them from your office? Should you investigate medicolegal considerations? Primary Care Optometry News Editor Michael D. DePaolis, OD, moderated a round-table discussion that was held during the Southwest Council of Optometry meeting in Dallas. Our well-respected panel members address these issues and share the decisions they have made in their own practices for their own patients.
Michael D. DePaolis, OD: In primary optometric practice, does nutritional supplementation even make sense? Is there a need for supplementation, and, if so, what supplements do you find yourself discussing with patients with respect to their prophylactic or therapeutic capabilities for various conditions?
Bruce E. Onofrey, OD, RPh: Supplementation falls at the bottom of the list of recommendations that I make when educating patients. I start with risk factors, those that patients can control and those they can’t. Those they cannot control are their age and race. Age-related macular degeneration is called that for a reason. It happens because patients get old. The incidence is higher in populations who are from northern Europe and who are white.
Then, there are factors that patients can control, which include smoking and diet. If patients care to try supplements, I give them some of the recent information based on literature studies, then they can make a decision from that. If they want the product, then I have samples.
Ron Melton, OD: I agree that it’s at the bottom of the list of our priorities, but it’s a high priority for many patients. In a lot of instances, they come in knowing more about the vitamin approach to macular degeneration and cataracts than we do. Because patients have so much knowledge about multivitamins for these conditions, we need to be able to give them guidance on what is in the medical literature and the facts about different products.
Changing diet, lifestyle
William Townsend, OD: I’ve thought a lot about this because low vision is sort of a subspecialty within my practice, and we definitely want to do something to help. A few years ago, I was much more inclined to give patients supplements. However, recent studies, especially those pointing to lutein and zeaxanthin, say that maybe the best way to get those vitamins is not necessarily through pills, but through diet.
I tell people that the best way to get lutein and zeaxanthin is by altering their diets. But if we recommend something like spinach, how will that affect the stability of, for example, anti-coagulant therapy?
Randall Thomas, OD: I have a master’s degree in public health and I realize that people are rarely willing or able to change their lifestyle or behavior. No eye doctor is likely able to convince them to change.
Dr. Melton: I think we’re obligated, just as family physicians are obligated, to educate patients on the importance of a healthy diet and exercise program. Most patients do understand that their eye health is a reflection of their general overall health status.
Dr. Onofrey: My father lived until he was 86. He smoked until he had a heart attack at age 78 and had bypass surgery. He didn’t smoke again. I agree that you can’t change everybody, but I think public health deals with large numbers of populations, not individuals. I’m a doctor; I deal with individuals. I believe that if we give them choices, they will make decisions based on the information we give them.
Carl Spear, OD: The fact that people are not going to change is the reason that we’re even having this discussion. That’s why patients are so susceptible to advertising and to what the clerk in the checkout line tells them. It’s easier to purchase a bottle of vitamins than to lose 50 pounds or quit smoking.
Dr. DePaolis: To Dr. Thomas’ credit, one need look no further than the increased prevalence of diabetes over the past decade. We’ve been talking about sedentary lifestyles and obesity forever, but we just aren’t getting a handle on it.
Dr. Townsend: It depends on the patient. Some patients say they hate spinach and will not start eating it. But others start eating dark green vegetables three or four times a week. Even their spouses make a change.
We’re cynical because we see so many people who are unwilling to change, but even if you can get a few people to make those changes, it’s worth it.
Dr. DePaolis: We make the recommendations for lutein and zeaxanthin, and we recommend that, whenever possible, patients get them through their diet. However, it’s nice to know that there are supplements for those who will not start eating broccoli or spinach four days a week.
Doxycycline, tetracycline, flaxseed oil
Dr. Melton: With meibomian gland dysfunction, I have seen tremendous benefit from using a 3- to 6-month course of doxycycline or tetracycline. Why not just recommend that, as opposed to the vitamin supplement?
Dr. Onofrey: First, we’re not completely sure about what tetracycline does. A recent study showed that it has dramatic anti-inflammatory effects as a topical medication, equivalent to a steroid.
Dr. Townsend: We have tried some patients on tetracycline and had some success, and then we switched over to flaxseed oil and had more success. One thing that worries me a little bit about tetracycline is the photosensitizing aspect of the drug. Have you had a problem with your patients getting sunburned?
Dr. Onofrey: I haven’t, but you have to be sensitive to that when prescribing in the summer time.
Linda Casser, OD: A subset of patients prefers a more natural path of therapy. I live in Oregon, and we even have institutions that train practitioners in the use of natural medicines. A subgroup of patients realize that traditional therapies haven’t been wildly successful for treating certain chronic conditions, and they are looking for alternatives.
Dr. Spear: Isn’t that part of the problem, though? They look at the “natural therapies,” and they think it’s not a medication.
Dr. Casser: Yes. I agree.
Ginkgo biloba
Dr. Spear: What about glaucoma and ginkgo biloba?
Dr. DePaolis: Robert Ritch, MD, is at the pinnacle of glaucoma care, and he’s starting to look outside the box and say that maybe they have some merit.
Dr. Onofrey: But Dr. Ritch phrases it in an interesting way. He’ll say that it increases end diastolic blood volume or velocity to the optic nerve; he’ll say it inhibits platelet aggregation; and he’ll give all the other benefits of the drug. Then, at the very end, he’ll say that it may be of some benefit in glaucoma.
Dr. DePaolis: We have to be careful. When you look at ocular surface disease and cicatricial ocular disease, there may be some merit to vitamin A therapy. Then, a lot of clinicians take a leap of faith and assume that it may be every bit as efficacious for the itchy, burning, marginal dry eye in their practice, when it probably isn’t.
Dr. Townsend: We can actually damage or do harm to a patient. For example, if a patient is a smoker and we tell him or her to start taking carotenoids, we have increased the risk for lung cancer by 27%.
Dr. Melton: Richard Wilson, MD, a glaucoma specialist at Wills Eye Hospital has written in the medical literature that getting your glaucoma patients that are obese and out of shape to lose weight and exercise routinely may be as effective as a medication at lowering intraocular pressure. I have definitely seen that in select patients where I’m having trouble controlling their intraocular pressure with medications.
We read these things, and we see them clinically, but I don’t think we recommend weight loss and exercise enough.
Dr. Onofrey: That goes to the heart of the issue. You can’t replace a bad lifestyle with a pill.
Dispensing supplements
Dr. DePaolis: If people take supplements indiscriminately and without professional guidance, they may actually do more harm than good. For that reason, does it make sense for us to dispense in office? Where do supplements fall? Are they more like contact lenses? Are they more like therapeutics? Are they somewhere in between?
Dr. Thomas: I don’t think we have definitive knowledge to guide patients at this time. We do not know which supplements do good, and we don’t know in what dosages and in what combinations. I tell patients that there is a growing base of evidence that if we take some lutein with other antioxidants that we might be able to postpone or prevent certain disease processes. I tell them to take a supplement with breakfast. I tell them that I don’t know if it will do any good for them, but it won’t do any harm.
I have never been asked where to purchase such supplements or if patients can purchase them from my office.
Dr. Townsend: I’ve read reports that say that patients may not be getting the amount of zinc, for example, that the bottle says they’re getting.
Dr. Onofrey: In cases when I want a supplement, I will use a large company’s product. Larger companies will make sure that their supplements are assayed and that they have the proper amount. They are the most cost-effective, and they’re the most widely distributed.
I don’t dispense in my office, but I do give samples.
Dr. Melton: I would like to see some guidelines from the American Academy of Optometry. The American Academy of Ophthalmology put out a complementary therapy assessment. In this, they give their position on the safety and efficacy of alternative treatments. This is the first step in determining whether or not to start dispensing out of your office. I think we’re so confused about the whole issue that it’s not how can we dispense, but what do we dispense?
Improved compliance?
Dr. DePaolis: Does anyone dispense? Does anyone have product lines in their offices that they educate the patient about and then either give samples of or dispense? Do you think colleagues of ours who advocate doing that feel they get better patient compliance?
Dr. Melton: The American Medical Association’s position on this is that you can dispense out of your office, but at no profit. So, I would ask colleagues who dispense if they would still dispense if they didn’t make a profit. In most cases, I think the answer would be no.
Dr. DePaolis: Can anyone build a compelling argument that dispensing, or even sampling in an office, improves compliance?
Dr. Thomas: I think sampling improves compliance because at least patients have a product or two in their hands to guide them when they go to purchase more product. Otherwise, they go to the drugstore and see walls of drugs. So, I think it’s important to give them some general guidelines on some brands to try.
Dr. Spear: I don’t see a problem with compliance. I see a problem with patients who are taking everything under the sun.
Dr. Casser: The practice of automatically mailing the product gives me cause for concern. It’s like a magazine subscription that you can’t cancel.
Dr. Thomas: Once a patient has established age-related macular degeneration, I think that recommending that they take a supplement is cruel. None of these are therapeutic agents; they are preventive agents. If we’re not proactive, the train has left the station. A lot of people may be tempted to recommend something because it gives patients hope, but with established, advanced disease, there is no hope.
Dr. Townsend: What about the person with early macular degeneration who starts making lifestyle changes?
Dr. Thomas: Then it might help because you caught them early. I’m talking about a patient with 20/400 vision.
Dr. Townsend: In that case, you may not be able to help the patient, but maybe you can help his or her children. I always ask the children if they smoke. Then, I tell them that if they continue to smoke, aside from the fact that their genetics are against them, they have an increased risk of developing the disease that their parent has. At that point, there’s nothing you can do for mom, but maybe you can help the daughter or the son.
Liability issues
Dr. DePaolis: What are the liability issues related to recommending and dispensing supplements?
Dr. Thomas: We’ve got to make sure our patients understand that no one really knows the answer. I just tell them what I would do if I had their disease, and I tell them that there is a lot of circumstantial evidence that some of these products may be helpful.
Dr. Casser: If an OD elects to dispense supplements from the office, I’m very concerned about delegating that role to staff. Some supplements’ sales models promote that, and I think that would expose the OD to liability.
We also have to be careful that the OD doesn’t exceed his or her scope of care. If ODs choose to dispense supplements, they need to dispense those associated with the eye and related disorders and not go beyond that.
A product that is visible in a practitioner’s office exudes an air of credibility to patients. ODs who elect to go down this path must realize what they have taken on and what they are portraying to the patient.
Dr. DePaolis: Your point is well taken. When someone goes into a health food store, he or she may be more skeptical than when buying a supplement from our office. Patients hold us to a little bit higher level of responsibility. If we recommend something, patients want to believe that we’re recommending it because it’s a better product for them.
Dr. Townsend: There’s also a liability issue from the standpoint of drug interactions. We don’t think about ginkgo biloba as a drug, but in combination with aspirin or non-steroidals, you can get some adverse events.
Dr. DePaolis: Ginkgo biloba and pre-existing anti-coagulant therapy is one example. Do any other drug interactions come to mind?
Dr. Spear: St. John’s Wort dramatically decreases the effect of many prescription drugs. It causes other drugs to be metabolized much more rapidly, therefore, reducing their effect.
Dr. Casser: I’ve had patients who have had gastrointestinal trouble after taking supplements, and I’ve had patients get headaches from high levels of vitamin C.
Dr. DePaolis: When taking zinc, is there any concern regarding competition with iron metabolism and copper metabolism?
Dr. Townsend: If a person takes zinc alone without copper, there would be a problem.
Dr. Onofrey: If you want to take a zinc supplement, don’t take it with iron or calcium.
For Your Information:
- Bruce E. Onofrey, OD, RPh, can be reached at Montgomery Eye Clinic, Lovelace Medical Center, 9101 Montgomery Blvd. NE; Albuquerque, NM 87111; (505) 275-4226; fax: (505) 275-4203; e-mail: Eyedoc3@aol.com.
- Ron Melton, OD, can be reached at 865 Linda Lane, Charlotte, NC 28211; (704) 944-4848; fax: (704) 945-4153; e-mail: meltonepec@aol.com.
- William D. Townsend, OD, can be reached at 1801 4th Ave., Canyon, TX 79015; (806) 655-7748; fax: (806) 655-2871; e-mail: drbill@Is.net.
- Randall Thomas, OD, FAAO, can be reached at 6017 Havencrest Ct.; Concord, NC 28027; fax: (704) 792-1647; e-mail: thomasepec@carolina.rr.com.
- Carl Spear, OD, can be reached at Novartis Ophthalmics, 11460 Johns Creek Parkway, Duluth, GA 30097-1556; (850) 939-1249; fax: (850) 939-7508; voice mail: (678) 415-3186; e-mail: Spearc@aol.com.
- Linda Casser, OD, FAAO, can be reached at Pacific University College of Optometry, 2043 College Way, Forest Grove, OR 97116; (503) 359-2766; fax: (503) 359-2929; e-mail: casserl@pacificu.edu.