Recommending ocular supplements blindly: more harm than good?

By Dr. Renee Rambeau,

The media is full of mixed messages, bombarding consumers (our patients) with unbelievable amounts of advertising including hundreds of messages about health, wellness and nutritional supplements.

As doctors, our patients look to us for sound advice regarding the addition of vitamins as prevention and treatment for ocular conditions including blinding eye disease like age-related macular degeneration. With the recent publication of the AREDS 2 study, the picture seems to be even more muddled than before. This post will help to clarify this controversial topic.

Research

– AREDS (NEI sponsored study) and other research published in the last several years have consistently produced statistically significant results that highlight the importance of recommending lutein & zeaxanthin to slow the progress of AMD. Few ODs would argue these results.  These studies show a minimum of 10mg/day of lutein and 2mg/day of zeaxanthin. So where is the controversy?

Supplements: empty promises?

Supplements are a dime a dozen but which products really contain the quality ingredients the labels promote?

-Just recently, major headlines were made by the New York Attorney General Eric Schneiderman requesting that hundreds of supplements be pulled from the shelves after a study by Clarkson University demonstrated that 4 of 5 supplements contained none of the ingredients listed on the label.

– Another study published online in the American Academy of Ophthalmology Journal in the fall of 2014 concludes that the “majority of top selling ocular nutritional supplements did not contain identical ingredient dosages of the AREDS or AREDS 2 formulation”.

Prescribing supplements

With all this conflicting information, what do we prescribe for our patients? And yes, I did say prescribe…after all we don’t hesitate to choose the proper antibiotic or intraocular pressure lowering drop if indicated by exam findings. Why should we hesitate to prescribe a product that research has proven to help slow the progression of a blinding eye condition?

The first recommendation is always whole foods; incorporating a variety of fruits and vegetables into a daily diet and aiming for 7-10 servings of these nutrient rich foods every day and a goal of 10mg of lutein and 2mg of zeaxanthin.  Here are just a few examples of dietary sources of these powerful antioxidants.

Good Food Sources of Lutein and Zeaxanthin (mg/serving)

Food/Serving
(1 cup)
Lutein and
Zeaxanthin
Lutein Zeaxanthin
Kale 20.5 – 26.5* 1.1 – 2.2*
Collard greens 15.3 5.1
Spinach 3.6 – 12.6* 1.7 – 13.3* 0.5 – 5.9*
Turnip greens 12.1 0.4
Broccoli 2.1 – 3.5* 1.4 – 1.6*
Corn, yellow 1.4 – 3.0 0.6 0.9
Peas, green 2.3 2.2
Orange pepper 1.7
Persimmons 1.4 0.8
Tangerine 0.5 0.2

*depending on variety and preparation

Source: USDA-NCC Carotenoid Database, 1998                                                                                                                        USDA Food Nutrient Database for Standard Release 13                                                                                          Hart and Scott, 199 HHN-1550B/0502

What happens if the patient in my chair is unwilling to try whole foods?  If the patient in my chair is hesitant to change his/her diet (or limited by other health conditions), my second recommendation is Juice Plus. Juice Plus is whole food nutrition in a capsule. The product is produced by dehydrating whole foods (fruits, berries and vegetables), utilizes a nutrition label instead of a supplement label and is backed by a significant amount of clinical research.

 

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Ocular Nutrition

By Dr. Katherine Bickle

Shortly before writing this, I had a conversation with a new patient regarding nutritional supplements. Her history was positive for pigmentary changes in the maculae, and she reported the use of a nutritional supplement. Since the patient is a current smoker, I discussed with her the importance of taking a supplement without beta-carotene.  She recalled this conversation with previous optometrists, and we discussed the presence of beta-carotene in several formulations. From this conversation, both the patient and I developed a better understanding of the various commercially available formulations. The importance of these discussions with our patients cannot be overlooked. Not only can your patients learn from your expertise, but you can also expand your knowledge.

You may know the formulation of certain brands you commonly recommend to your patients. For those you aren’t familiar with, how do you easily distinguish among the marketed brands?  What are we doing on a daily basis to provide our patients with optimal care while striving to improve each patient’s quality of life?

Discussion with your patient

Recommending the proper nutritional supplement for your patient with AMD, MGD, and/or dry eye disease requires a thorough medical history, examination, and discussion with your patient.

Questions to consider asking your patient include:

  • Do you have a personal history of AMD, MGD, or dry eye disease?
  • What has been the impact of previous and current condition(s) and treatment(s) on your quality of life?
  • Which supplements, if any, have you used previously?
  • Which supplements have resulted in bothersome side effects for you?
  • How often do you take the recommended nutritional supplements (if previously prescribed)?
  • What are your short and long-term goals related to vision, comfort, and health?

AMD, MGD, and Dry Eye

Practitioners have differing philosophies on prescribing nutritional supplements for conditions. The AREDS (Age-Related Eye Disease Study) and AREDS2 have provided us with valuable information that we can incorporate into our daily patient care. More information regarding the AREDS2 can be found at http://www.areds2.org. While the AREDS2 reported that the addition of omega-3 fatty acids was not beneficial in the treatment of AMD, the literature suggests that omega-3 fatty acids may be beneficial for those with MGD and/or dry eye disease.  The International Workshop on MGD lists increasing dietary omega-3 fatty acid intake in the treatment algorithm for MGD. If you’re considering recommending omega-3’s to a patient, it is important to ask your patient about the use of blood thinners. Omega-3’s have been shown to cause additional anticoagulation effects when used with blood thinners. It is important to recommend an appropriate dose of omega-3’s that do not significantly raise the patients’ international normalized ratio (INR).

There are several commercially available supplements available for our patients. Do you have one supplement you recommend or do you give the patient options, and let the patient choose?  Do you make your recommendations from reading the literature, speaking with colleagues, or from your personal experience? While supplements may be less expensive or have less side effects than some prescription medications, your patients may not perceive the value in taking these supplements unless you discuss the potential benefits with the patient.  I encourage you to follow-up with your patients regularly regardless of your recommended treatment. When treating a patient for MGD and/or dry eye, discuss how their symptoms have changed since beginning the treatment. These are questions you can ask your patients directly or have your staff provide questionnaires for the patient to complete.

Patients appreciate the personalized care you provide them, the time you spend addressing their needs, and the appropriate treatment options you prescribe. Incorporating ocular nutritional supplements into your treatment plan can improve your patients’ ocular health and quality of life.