Dispensing vitamins, nutritional supplements is an individual decision

Issue: October 1999

Product sales, a key patient service

Jerome Sude, OD: Since the passage of the Dietary Supplement Health and Education Act of 1994, interest in the therapeutic potential of natural dietary supplements on the part of health care professionals, customers and the general public has literally exploded. The changing demographics of the aging baby boomer population have also contributed to the rapid growth of the natural supplements market. According to a 1996 survey by Yankelovich Partners (an independent market research firm), 80% of female consumers expressed the wish that their doctors were more accepting of nontraditional, alternative forms of health care. I and many doctors view product sales as a key patient service to better allow optometrists to ensure patient compliance, monitor outcomes, provide instructions about product use and make available higher quality choices than may be available through traditional retailers.

During the past several years, there has been a tremendous amount of information in medical journals supporting the use of supplements for conditions such as cataracts, macular degeneration and glaucoma. This information is readily accessible through medical school or hospital libraries.

Before doctors decide to recommend nutritional supplements in their practices, they should be in touch with the company distributing or manufacturing their products. Talk to their biochemists and determine if formulations are determined from good data. Find out from companies what studies have been performed on their products, and access those studies. If products are to be sold for profit, the patient must be made aware that the doctor has financial interest in that sale. We must be very careful not to allow regulatory agencies to micromanage our practices, especially when what we are doing is in the best interest of our patients.

Jerome Sude, OD, can be reached at 518 West Ave., Tallmadge, OH 44278; fax: (330) 630-2173. Dr. Sude has a direct financial interest in the Pharmarex product line. He is not a paid consultant for any companies mentioned.

Research your decision to dispense

Frank M. Davis, OD, MDiv, JD: I am fairly confident that the current medical research supports the notion that patients diagnosed with age-related macular degeneration (AMD) will likely benefit from nutritional supplementation.

With other ocular conditions, such as dry eye syndrome and cataracts, I am not as comfortable recommending vitamins as a highly effective treatment option, but I also feel that it should be up to the optometrist’s professional judgement whether to dispense nutritional supplements out of the office.

From a legal liability standpoint, the OD needs to know that if he or she is dispensing supplements, then he or she will be held to a “specialist” standard-of-care in a malpractice lawsuit and will be expected to know everything about them. The OD needs to thoroughly understand how the body absorbs supplements, when they should be taken, the appropriate dosage and potential side effects. If the OD chooses to dispense vitamins for profit, then the OD needs to be well prepared to support his or her specific supplement recommendations if the patient files a lawsuit claiming that these recommendations caused bodily harm, for example. To help protect the OD from legal liability, I offer the following suggestions:

Maintain a file of the articles and/or books that serve as the basis for your diagnosis and treatment recommendations.
Become familiar with the side effects of each supplement you recommend.
Make sure the patient’s file contains a thorough health history, including any vitamins, herbs and nonprescription supplements that the patient is taking on his or her own.
Record your specific dosage recommendations in the patient’s record.

Frank M. Davis, OD, MDiv, JD, is a cum laude graduate of the Capital University Law School. He practices optometry and comanages refractive surgery patients. He may be contacted at 50 North State St., Westerville, OH 43081; (614) 882-7786; fax: (614) 882-1012. Dr. Davis has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned

It's ethical if guidelines are followed

Douglas Villella, OD: The following issues are well supported in current literature: oxidative damage at the level of the outer segments of the photoreceptors plays a significant role in the development of AMD; high serum levels of antioxidants (for example, vitamins C and E and carotenoids) lower the risk of AMD; a diet rich in carotenoids, lutein and zeaxanthin (found in carrots, spinach, broccoli, kale and collard greens) is correlated with a reduced risk of AMD; and smoking, hypertension and hypercholesterolemia are associated with an increased risk of exudative AMD. As part of a responsible wellness and prevention program, eye doctors should counsel all adult patients on proper diet, smoking cessation, wearing UV protection and the issue at hand here, vitamin usage.

The Age Related Eye Disease study (a multicenter study sponsored by the National Eye Insititute), the results of which will be released next year, will provide important data regarding the value of vitamin supplementation but will still leave many unanswered questions. For example, some herbs and supplements that have been shown to be beneficial are not part of this study. Many patients do not want to wait 10 years for a definitive study and want to take these potentially beneficial supplements. While patients deserve this information, it is difficult for the average clinician to keep track of all the newer, potentially beneficial compounds. For this reason, it may be helpful to consult a company such as Science Based Health (www.Science BasedHealth.com), whose job is to put into an eye vitamin what is suggested by current literature.

I believe it is ethical for an eye doctor to market vitamins to patients provided certain guidelines are followed. The doctor’s vitamin recommendation should be backed by science, be of outstanding quality and content and be affordable to the majority of patients. The doctor should make the patient aware that a profit is derived and should provide the freedom for the patient to purchase the vitamin elsewhere.

Douglas Villella, OD, is in private partnership and is staff vision rehabilitation optometrist at Health South Great Lakes Rehabilitation Hospital. He can be reached at 300 State St., Suite 202, Erie, PA 16507; (814) 454-6517; fax: (814) 454-0604; e-mail: doogie@erie.net. Dr. Villella has a direct financial interest in Science Based Health. He is not a paid consultant for any companies mentioned.

I recommend, but so not sell

Larry J. Alexander, OD: I am confident that lifestyle modification and proper diet can radically modify morbidity and mortality. While most of the research supporting exercise, diet, weight control and nutritional supplementation is related to other health fields, specifically cardiology, more research is evolving in the eye field daily.

Certainly, no one can contest the positive effects of vitamin E, vitamin B-12 and folic acid for controlling cardiovascular risk. The benefits of antioxidants to the eyes is a bit more elusive because of the conflicting studies, but certain supplements, such as lutein, have considerable support in the literature. I personally have a sizable collection of literature to support the advice to patients to modify lifestyle and consider nutritional supplementation. The patients must realize, however, that there are potential side effects and that there is no “magic pill” to reverse the effects of a lifetime of abuse to the system.

The other hard fact is that there is nothing else out there to cure macular degeneration and cataracts. All intervention, with the exception of cataract surgery, comes up short.

The decision to advise patients on the types and brands of nutraceuticals to buy is very individual to the doctor. I believe that patients are going to purchase the supplements anyway, with or without your professional input. Why not advise them on the best product out there? Our practice recommends and softly markets the concept of wellness to prevent eye disease. We recommend a Wellness Rx. While we do not sell vitamins in the office, we do actively recommend a few products based on our belief in the products.

I have no intention of getting involved in pyramid practices within the office but do see a definite advantage to becoming a professional source of advice for my patients. I know they appreciate it. I do not, however, believe that it is unethical to advise on any product, whether it be a nutritional supplement or a pair of contact lenses. Who better to advise the patient: a doctor or a clerk in the grocery?

Larry J. Alexander, OD, is a consultative optometrist and practice administrator at the John Kenyon Eye Center in Louisville, Ky. He can be reached at 6907 Bridgepoint Blvd., Prospect, KY 40059; (502) 895-2910; fax: (812) 288-7479. Dr. Alexander has a direct financial interest in Science Based Health. He is not a paid consultant for any companies mentioned.