BLOG: ‘Selling vitamins’ – another way to reduce patients’ risk

Last week I attended and led a discussion for my local study group meeting of the practice alliance I belong to. The topic was: What have you done in your practice over the past year that has increased revenue, office productivity or patient satisfaction?

The answers discussed and the pearls derived from these group discussions always amaze me. Independent optometrists are also independent thinkers, and what we can learn from each other is invaluable.

I was happy to hear one of my colleagues report that she had implemented prescribing and in-office dispensing of carotenoid supplements to build macular pigment. She stated that this had significantly increased revenue and patient satisfaction. However another colleague chimed in and stated that he had tried prescribing and dispensing these same supplements, but it made him uncomfortable to “sell vitamins,” so he stopped. Really?

So I asked a few questions:

Q. Do you refract and prescribe glasses and contact lenses?

A. Of course!

Q: Do you diagnose and treat eye infections and prescribe antibiotics and antivirals?

A: Yes.

Q: Do you diagnose and treat glaucoma and prescribe IOP-lowering agents?

A: All the time.

So, let’s think about this for a minute. Low macular pigment optical density (MPOD) has been identified as a potential biomarker of risk for developing age-related macular degeneration and for AMD progression. Additionally, it has been shown that those with low MPOD have significantly more problems with glare and have diminished contrast sensitivity.

By definition, a biomarker is a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes or pharmacologic responses to a therapeutic intervention. To me, this begs the question: What is the difference between measuring MPOD, blood sugar, cholesterol or blood pressure?

They all fall under the definition of a biomarker in which a response to a therapeutic intervention can be measured. Adding macular carotenoids to one’s diet through food or supplementation produces a therapeutic response that is realized through increased blood serum levels and increased MPOD.

Now, what is the difference between prescribing glasses, antibiotics, antivirals, allergy medications, dry eye medications, glaucoma medications or a carotenoid supplement? In my book, none. These are things we prescribe all the time to better one’s quality of life or prevent ocular damage.

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I touched on the concept of pre-AMD in a previous post. Risk factors for pre-AMD include family history, high body mass index, smoking and low MPOD. Three of these four risk factors are modifiable.

Because AMD is the leading cause of blindness in people older than 55 in developed countries, why should we ever feel uncomfortable about prescribing a potentially sight-saving supplement?

Whether or not you measure MPOD in your practice, you can still recommend carotenoid supplements to your patients with pre-AMD. We have measured MPOD in our clinic for several years, but our model is to do this as a value-added test; patients have the option of paying an additional fee for the testing. Those who do not have testing but have other risk factors, especially family history, still get an education from me on macular pigment.

Supplement manufacturers can provide you with the proper tools for this, shortening explanations to only a couple of minutes. Or you can easily have this conversation with an eyeball model, scratch paper and a pen (see another previous post, “The cocktail napkin talk”).

Sometimes patients note a family history of vision loss, without identifying AMD as the cause. In this situation, I ask a few probing questions. Usually the answer derived is that their loved one did in fact lose vision from AMD and the patient just did not realize to call it as such. They say, “Mom could see all around her, but not right in front of her” or “She could not read, see TV or even faces.” With a little education, many times they ask to have their MPOD checked.

Regardless of whether I know their MPOD level or even if it is measured as normal, I still always prescribe a supplement for those with a family history of AMD. I simply explain it is like sunscreen for their macula, and it is impossible to put on too much. The vast majority of patients comply and take the supplement.

I started off this post with the comment of a colleague stating that it made him uncomfortable to sell vitamins. Hopefully you now understand that it is important to do what is best for our patient’s welfare, and proper carotenoid supplements are not found at the local grocer or health food store. I am a firm believer that all three macular carotenoids – lutein, zeaxanthin and mesozeaxanthin – are needed to properly build MPOD.

There is a multitude of peer-reviewed scientific papers pointing to this. Read them and make your own decision. Hopefully, after doing a little research, nobody reading this post will be uncomfortable selling vitamins.

References:

Bernstein PS, et al. Vision Res. 2010;50(7):716–728.

Loughman J, et al. IOVS. 2012;53(12).

Meagher KA, et al. Br J Nutr. 2013;110(2).

Sabour-Pickett S, et al. Retina. 2014;34(9). doi: 10.1097/IAE.0000000000000174.