We’ve been spoiled by our own success. In virtually 99% of cases, cataract surgery can restore sight, sometimes to a level that exceeds pre-cataract vision. As a result, we’ve been penalized by the government and other third-party payers with lowered reimbursement for more and better work. We’ve become "refractive surgeons," turning to new technology not yet controlled by government regulators to augment our income.

For many ophthalmologists, the core raisons d’être of ophthalmology are still cataracts, glaucoma, macular degeneration and other degenerative conditions. But here, too, government has targeted us for continuing reimbursement cuts, so we’re looking with renewed interest at wellness and prevention through nutritional supplements, also called "nutriceuticals," and vitamin therapy. Nutriceuticals are nutritional supplements designed to meet the needs of specific degenerative problems such as macular degeneration, cataracts and glaucoma.

Back to the future

Physicians generally accept the claims of pharmaceutical companies but ignore the evidence of nutriceuticals’ efficacy. Some want double-blind studies and FDA approval before they’ll accept anything because they’ve been conditioned to this in medical school. They say there hasn’t been enough documentation of nutriceuticals’ efficacy.

In fact, there’s a growing body of evidence that the antioxidant vitamins and minerals incorporated into some products are effective in slowing or reversing eye diseases, but most of us don’t have the time or motivation to read nutritional science journals. We’re more concerned with new technology in refractive surgery and the latest cataract techniques. We’re accustomed to performing "miracles," not preventing disease.

We should also remember that many of the drugs we use every day never underwent double-blind studies, nor were they approved by the FDA. Examples include commonly used medications such as aspirin, digitalis and morphine; vaccines for smallpox and polio; and antibiotics such as penicillin and streptomycin.

Before the "pharmaceutical revolution" (and in many parts of the world today) herbs and other phytochemicals were investigated and used for medicinal purposes. In a sense, modern medicine is going "back to the future" to find ways of preventing or delaying conditions which have been treated, in the past half century, by surgery or pharmaceuticals.

Vitamins, free radicals, antioxidants and cataracts

We’ve learned a great deal about vitamins, free radicals and antioxidants over the past 10 years, but still many of us are reluctant to use them because we weren’t trained in these areas. We still aren’t familiar with the terminology or the science, and we’re sensitive to the criticism of others who feel that we should limit ourselves to "traditional" treatments. Maybe some explanations will help.

A free radical is an atom or group of atoms characterized by one or more unpaired electrons that result in electrochemical instability. Free radicals are produced by every cell in the body in the oxidative process of normal metabolism, as well as in the metabolism of environmental pollutants. They also result from solar radiation.

In normal metabolism, the principal free radicals are superoxide, peroxide, hydroxyl and singlet oxygen. Free radicals aggressively interact with molecules in cell walls, nuclei, mitochondria and DNA, taking or giving electrons randomly. This in turn destabilizes those molecules and generates a cascade that ultimately destroys the cell, the organ and the organism. This is the aging process.

Free radicals are neutralized by antioxidants – substances that, even in low concentration, significantly inhibit the rate of oxidation free radicals cause. They’re classified by how they work and where they’re found:

• Natural enzyme antioxidants are found in cells.
• Preventive antioxidants are found in plasma.
• Scavenging antioxidants are found in plasma and serum.
• Dietary antioxidants are found in foods like herbs, fruits and vegetables.

Free radicals that aren’t neutralized produce the oxidative/reduction reaction. The continued production of free radicals over time, plus genetic influences, produce accumulation of damage (aging, cancer, degenerative disease and death).

The 1989 Conference on Free Radicals and Vitamins in Public Health concluded that, "Free radical damage is the principal cause of heart disease, cancer, cataracts and ARMD; and the antioxidant micronutrients, particularly vitamins A, C, and E, are the principal line of defense."

Several articles have also documented the effectiveness of nutritional components in preventing or delaying the development of cataracts. One such article (Am J Pub Health 1994; 84: 788-792) stated, "17,000 American physicians on daily multivitamin supplements had a 25% reduction in the incidence of cataract." Another (Br Med J 1992; 305: 335-339) reported a study in which "women who consumed spinach regularly had a reduced incidence of cataract formation."

The evidence for treating other diseases

Evidence also indicates that nutriceuticals can help in these diseases:

• ARMD
. This has received a great deal of attention among researchers, with articles confirming the relationship between nutritional supplements and reduced incidence and severity of ARMD. One such article (JAMA 1994; 272: 1413-1420) pointed out that "Consumption of 6 mg of lutein per day lowered the risk of ARMD by 43%," and another (Am J Clin Nutr 1995; 62: 14485-14615) stated that "Carotenoids and xanthophylls may retard some of the processes in the retina that lead to ARMD."
• Diabetes
. Articles on research into antioxidant effects on eye disease appear with increasing frequency. The European Journal of Clinical Investigation (1997; 27: 141-147) pointed out that "In onset of diabetic eye complications, a decrease of free radical scavengers is shown to be associated with oxidation of lens and vitreous protein . . . and can be helped by antioxidants." Chromium and other vitamins and minerals can also help, as I’ll discuss later.
• Hypertension and cancer
. Multivitamin and mineral supplements are receiving increased attention in other specialties, particularly gynecology, cardiology and internal medicine. The Journal of the American Heart Association (1998; 98) pointed out that "Hypertensive men with diets high in potassium and magnesium have a substantially reduced risk of stroke." The Annals of Internal Medicine (1998; 129: 517-524) reported that "In women taking folic acid supplements for 15 years, the risk of colon cancer dropped 75%," and "Foods rich in folic acid are less effective than use of supplements in enhancing folate levels." Another significant report on the use of antioxidants in cancer prevention appeared in the New England Journal of Medicine (1993), saying "87,000 female nurses on 100 IU of vitamin E and selenium reduced their risk of cancer 13%, and overall death rate 9%."

There are some pitfalls to keep in mind. Many people, relying on the advice of health store clerks and "multilevel marketers," are misinformed and take too much of some things and too little of others. A couple of references here will speak to this problem:

Ophthalmology

(1998; 105: 12: 2264-2270) says, "When vitamin E is given in high doses along with beta-carotene in insulin dependent diabetics with retinopathy, the disease appears to increase in severity." And Annals of Epidemiology (1995; 5: 490-496) comments, "Excessive levels of zinc may actually elevate serum lipid levels and increase the risk of cardiovascular disease."

Three good supplement ingredients

Modern diets have been shown to be insufficient in elements that are necessary for full nutrition, and choosing the right nutritional supplements can change your patients’ lives. It can also help you avoid the pitfalls I spoke of above.

Look at some of the nutritional supplements that go into OculaRx (one of the most popular products):

• Grape seed extract
: This substance is 20 times more powerful against free radicals than antioxidant vitamin C and 50 times more potent than antioxidant vitamin E. It was discovered through a study of the unusual longevity of people in southern France who ate foods that we know cause heart disease and arteriosclerosis, yet who had a heart disease rate barely half that of Americans.
Researchers assumed their longevity was related to the wine they consumed. But studies revealed that it wasn’t just the wine, which contained strong antioxidants from grape skins, but the seeds of the grapes from which the wine was made. In combination with other antioxidants, grape seed extract’s effectiveness is even stronger.
• Beta carotene, vitamin E and vitamin C.
Arteriosclerosis and coronary heart disease result from cholesterol building up in the inner muscle walls of the major vessels. Scientific studies have revealed that antioxidant compounds can prevent and reduce cholesterol deposits. The secret is getting enough of these compounds. Diet alone doesn’t provide enough, so nutritional supplements are necessary. Some antioxidant vitamins have been tested, alone and in combination.
In animal tests, vitamin E was shown to be 45% effective against cholesterol, and beta carotene was 85% to 90% effective. Vitamin C was found to be 90% effective, but the combination of all three was found to be more than 95% effective. Combining all three had absolutely no adverse effects.
No heart drug on the market even comes close to such a benefit/risk ratio, yet many physicians scorn these supplements and prescribe potentially toxic prescription drugs instead.
• The essential mineral, chromium
. Diabetes treatment is misguided. It aims to reduce blood sugar with insulin or oral drugs despite the fact that 90% of diabetics are non-insulin-dependent, or Type 2, diabetics. Rather than having an insulin deficiency, these patients produce more than normal levels, but their bodies are unable to utilize it. Diabetes is a degenerative disease of metabolic insufficiency, not excess insulin.
Chromium is an essential trace mineral "co-factor" that activates insulin utilization. Diabetes treatment without adequate chromium intake overburdens the body’s sugar regulatory mechanism. The body’s reaction to elevated blood sugar is to try to clear this excess by stimulating the kidneys to excrete large volumes of urine. This is why thirst, excessive drinking and frequent urination are classic symptoms of diabetes.
High urine excretion causes huge losses of the nutrients needed to maintain good health, including vitamins B1, B6 and B12, as well as essential minerals magnesium, zinc and chromium. This loss of vital nutrients is perhaps the primary reason for the deterioration of eyes, kidneys, peripheral nerves and vessels that so often occurs with diabetes.
These complications would result from any condition that caused such massive nutrient depletion. Once you realize this, you can appreciate why nutriceutical supplementation of the diet is key to avoiding, minimizing and even reversing diabetes and its harmful effects. We need a balanced formula of antioxidants, multivitamins, essential minerals and special ingredients (including herbal compounds) to meet the body’s needs.

Take charge

Because they need information on nutritional supplementation, people turn to whatever source speaks with authority. Unfortunately, that’s frequently the lay press and people who sell vitamins and nutritional products. We’ve turned our backs on this important area too often.

Antioxidant vitamin and nutritional supplements will play an increasing role in eye care. Research and outcomes analysis will provide some answers to remaining questions, but for now we must use the presumptive evidence reported in journals – and our own experience – to bring nutritional supplementation into mainstream medicine and to take the lead in meeting the needs of an aging population.

Dr. Thornton is medical director of the Thornton Eye Center, Nashville, Tenn., and past president of the American Society of Cataract and Refractive Surgery. He has a major interest in wellness and prevention, and is consultant to the ScienceBased Health Company.

 

Win-Win with Nutriceuticals

Multilevel marketing and patient interest drive this doctor’s success.

By Edward Gelber, M.D.,

Miami, Fla.

Ninety-five percent of patients take some form of nutritional supplementation. However, 90% have no clear idea why they’re doing so. They crave quality information about nutriceuticals. They also value our opinion; they’re not satisfied with obtaining information from the media.

In 1988, when an article regarding the efficacy of zinc in macular degeneration appeared, (Arch Ophthalmol, "Oral Zinc in Macular Degeneration," Newsome D.A., Swartz M, Leone N.L., et al.) I saw an opportunity to give patients with this problem some hope for prolonged useful vision instead of a doomsday scenario.

I began to offer antioxidant vitamins (containing zinc picolinate), which I had privately labeled. I enjoyed immediate success. However, my staff became encumbered with tracking patients’ appointments, inventory control and record keeping. I abandoned the project, but I knew that I’d return if I could solve the inherent problems.

The solution came in 1995, when I was introduced to a network marketing company with a central distribution point. Now, I simply stock enough products to introduce my patients to them and then refer the patients to a toll-free number if they wish to continue taking the nutritionals. I’m credited for the sale whether they buy the products from me or directly from the company. An added benefit to this approach is that the initial financial outlay is minimal.

If you’re interested in venturing into this arena, you must first take a few steps.

• Believe nutritional supplementation is important
. Only reading the current literature can convince you. Sometimes, you must accept that good data will take many years to emerge and common sense must prevail in the interim.
• Take the high-quality product yourself
. With potent antioxidants you’ll feel an increase in your energy level within 2 weeks.

Armed with some fundamental knowledge of nutriceuticals and your own satisfaction, you’ll be ready to treat patients.

I spend some time discussing nutriceuticals with a patient, after which I refer him to my wellness counselor. This is the same person who handles other marketing projects for me and has detailed information on the products. She spends as much time as necessary informing each patient of the efficacy of nutriceuticals. This consultation is a value-added experience for the patient when handled properly.

I view the revenue stream from nutriceutical sales as ancillary profit, like my contact lens business and optical sales. However, in addition to the cash flow from direct sales, I receive ongoing residuals from the individuals and practices I’ve helped to get started in the nutriceuticals business and who are now in my network.

When a patient tells me how the nutriceuticals I recommended speeded his postsurgical recovery or boosted his energy, I feel that I’ve accomplished the primary goals of my practice: to improve my patients’ quality of life, and to exceed their expectations of care and service.

Dr. Gelber is medical director at Miami Eye Center in Miami, Fla. He’s also on the voluntary faculty of the University of Miami. He can be reached at 800-335-4752 or e-mail at docgelber@aol.com.