Picking the right nutraceuticals for eye health supplementation

To successfully evaluate patients for nutrient deficiencies, it would be helpful to assess their nutrient intake. Image credit: AdobeStock/MariaShchipakina

Nutritional support for visual disorders is a rapidly growing area of eye care. This can be a specialization of your practice that offers your patients the best of traditional and complementary vision care.

The practitioner must first accept that nutritional support is a valid addition to treating eye disease. Although conventional medications certainly have their place, many practices choose to integrate nutrition that can serve to support their treatments. This is the core concept of “integrative optometry.” Many patients prefer the use of natural, effective, and less invasive interventions whenever possible. This process also shows that the practice is respecting patients, listening to their health concerns, and taking them seriously, as well as using good medical judgment.

Figure. FDA Regulation Requirements

The Dietary Supplement Health and Education Act was enacted in 1994 and defines dietary supplements. However, these products must have a disclaimer: “These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, cure, prevent, or treat any disease.” This means that these products are considered foods, but not drugs. However, manufacturers are still responsible for safety and effectiveness. Foods and supplements must undergo premarket notification, whereas drugs need premarket approval, both of which the FDA mandates. As long as a nutrient is considered “Generally Regarded as Safe” (GRAS), a designation that a chemical or substance added to food is considered safe by experts and thus exempted from the usual Federal Food, Drug, and Cosmetic Act food additive tolerance requirements, it can be used in a supplement (Figure).

There are 4 general misconceptions regarding vitamins and minerals for patient care:

• They are completely safe. Although that is mostly true, nutrients can be abused and cause dangerous effects if not taken appropriately, just like any OTC item.
• They are ineffective. Nutrients’ effectiveness is much more subtle and long-term than that of drugs, but nutrients are effective nonetheless.
• They are all the same. This is not true, especially when a multivitamin is considered. The type, form, and amount of each nutrient can make a major difference in how it works.
• More is better. This is the most common misconception; just because a certain amount is effective, it does not mean that 10 times that amount is 10 times more effective.

To successfully evaluate patients for nutrient deficiencies, it would be helpful to assess their nutrient intake. That sounds like a daunting task and one best left for nutritionists. However, you can usually get a good sense of their basic diet by asking several general questions:

1. How many servings of fruits and vegetables do you eat daily? (Note: 1 serving is one-quarter cup or a handful). Be aware that people will always overestimate this amount, and French fries do not count as a vegetable serving. The CDC recommends 9 to 13 servings per day.
2. How many times a week do you eat fish, and what kind do you eat? We now know that eating smaller fatty fish (sardines, mackerel, anchovies, herring, salmon, etc) at least 3 times a week is best for omega-3 intake.
3. Do you eat baked goods? These contain simple sugars and “bad” carbs, which is worse than eating “bad” cholesterol. Substituting good carbohydrates in vegetables is better.
4. Do you take a full-spectrum multivitamin/mineral supplement? Although eating a balanced diet should supply an adequate vitamin intake, it rarely happens, so a supplement is usually required. Also, a few pills will not overcome a bad diet.
5. Do you limit the portion of food you eat at each meal? Most people eat until the plate or box is empty. Limiting portions can allow you to eat better, more nutrient-dense foods.

Given the national state of optometric licensing, just about every optometrist is allowed to order blood panels. An exact review of vitamin levels in the blood will offer an excellent road map of how to proceed in making the appropriate recommendations to your patients. However, knowing some of the science and how nutrients are used in supplement form would be helpful. For example, it is often overlooked that there are 8 different forms of vitamin E, and almost all supplements use the tocopherol form and not the tocotrienol form, which has many benefits. Also, vitamin D should be in the D3 form and not D2, which is one-third as effective. Basic information can be reviewed at the National Institutes of Health, Office of Dietary Supplements website.

So what should be considered in a vitamin supplement to help eye health? Dozens of companies in the US alone make hundreds of different products in this category. Patients don’t want to be taking handfuls of pills, so getting as much nutrition as possible in fewer pills is ideal. The products should have a valid scientific rationale available for anyone to review and a website that puts science first before price and marketing. Any company promoting making “millions of dollars” on selling their products should be considered suspicious. Health goals should be directed toward patient well-being; the income will follow.

The first thing the practitioner should look for is a product that is a good blend and balance of nutrients formulated around the very latest science in nutritional medicine. This will take a bit of time, considering the number of companies and products out there. And it is unlikely that the practitioner will become a biochemist in the process. Ensure that the scientific rationale for their ingredients is available (usually on their website).

One thing to consider is the form of the pill being offered. Hard-pressed pills are typically found not to break down effectively in the body. A capsule or gel cap is preferable. Liquids are also an effective way to absorb nutritional supplements.

A full-spectrum supplement should be designed to slow the progression of chronic degenerative disease, including all eye diseases. There should be efficacious amounts of properly balanced fat-soluble vitamins, particularly related to the latest vitamin A and D research. Vitamin A should be in the retinol form, not beta carotene. It should contain potent amounts of the full spectrum of B vitamins to properly maintain homocysteine, specifically B₆, B₁₂, and folic acid. There should also be 400 IUs of the complete spectrum of Vitamin E with a balanced mixture of both natural d-alpha tocopherol (not the synthetic form of dl-alpha tocopherol) and mixed tocopherol oils containing gamma and delta tocopherols and tocotrienols.

Supplemental iron has been linked to heart disease, so it should be iron free for men and postmenopausal women. It should also contain the whole army of “job-specific” antioxidants that prevent free-radical damage and neutralize the effects of previous oxidative damage. In addition, there should be efficacious amounts of eye-specific carotenoids: lutein esters (not free lutein) and pure zeaxanthin, to ensure proper xanthophyll transport to the retina. Meso-zeaxanthin is unnecessary in a supplement because it is formed from lutein in the visual cycle. The supplement should also contain the spectrum of minerals in their most bioavailable form to ensure proper cellular bioelectrical and enzymatic response. For example, zinc oxide (found in AREDS trial formulas) is the poorest absorbable form of zinc.

Although AREDS has become the gold standard for age-related macular degeneration therapy, the study data did not show efficacy in the early stages of the disease (only slowed progression from stage 3 to 4). It is better to recommend a full-spectrum supplement to support overall health.

Office protocols for approaching the patient should be done in a caring manner. First, diagnose the condition and carefully explain the options to the patient. Then hand the patient a brochure that fully explains the recommended product. If they decide to purchase it right away, take the bottle to the front desk to dispense as a convenience to the patient. If they want to consider purchasing it later, let your office staff know (via a routing slip) that the product was discussed with the patient. They can again ask the patient if they wish to make the purchase at the initial visit or later. Either way, the patient knows it is available and something that can assist in their treatment. A 2-week follow-up phone call asking about the status of the nutrient recommendation can increase adherence by up to 50% in many cases. This also demonstrates the doctor’s commitment to the welfare of the patient.

Learning about nutrition can be a lifelong proposition, but it can be extremely beneficial to you and your patients. Although we are not biochemists or nutritionists, we should learn some of the basics of nutrition to make intelligent decisions about what to recommend to our patients. If we don’t, someone else will.