Most of us are becoming more aware of the value of promoting good nutrition and a healthy lifestyle to our patients. And, contrary to popular belief, we now do have the science needed to responsibly recommend nutritional supplements to our patients.

Patients are also becoming aware. They're better educated by the media and the increasing number of health food stores. We have as many nutritional publications as we do scientific.

Let's review exactly what our role should be in this era of health-conscious patients.

The increasingly middle-aged and health-conscious Baby Boomers -- especially those affected by the loss of a parent's or grandparent's vision -- are looking for prophylactic options.

Many major ophthalmology teaching institutions are also conducting controlled prospective clinical studies to evaluate the role of nutrition in macular degeneration and cataract. (See "Major Nutrition Studies").

This new activity contrasts with many current practices in medicine. As scientists, we tend to approach our knowledge one study at a time, rather than by achieving a full understanding of how a biological system works. But as healers, we can't expect to follow the action of a chemical compound in the eye without investigating how it interacts with other compounds throughout the body.

For example, we know that light, focused through the cornea and crystalline lens, creates photic stress and a high metabolic demand on the retina. But what many of us might not consider, and what Chinese and Indian physicians have known for years, is that the liver plays a significant role in providing the retina with much-needed nutrients, especially as a person ages.

The liver stores fat-soluble vitamins, metabolizes vitamin B and manufactures and stores glutathione, a major antioxidant that helps keep the crystalline lens healthy.

We're fortunate that many epidemiological studies show that people with high vitamin C or carotenoid and tocopherol (vitamin E) levels are at less risk of cataract development and, to some extent, macular degeneration.

The results are measurable. Should we not share this information with our patients? Remember, there are people who are searching for complementary options in the treatment and management of their glaucoma, AMD, dry eye or cataracts.

We need to be confident that we're providing reliable information and not jeopardizing our patients' health when we recommend nutritional supplements. So what are some safe guidelines and how should you follow them?

First, consider that any patient can benefit by consuming less than or equal to 10,000 IU of vitamin A and 1,000 IU of vitamin D each day. Toxicity is not an issue at these levels.

Research in heart disease has shown folic acid, vitamin E and vitamin C help minimize arteriosclerosis and other conditions contributing to heart disease. Cancer research has shown that selenium, a co-factor for vitamin E, and glutathione and other trace minerals which are cofactors for cellular enzymes are important.

Many of the good eye vitamins and general vitamins include lutein and zinc, two important protectors. Bioflavonoids, which give fruits color, help minimize the effects of ultraviolet radiation exposure on the eye. They also assist vitamin C in building strong capillaries and collagen.

That's why you're seeing so much excitement this year over the inclusion of lutein in supplements. Use of this additional ingredient follows research by Dr. Joanna Sedden, M.D., and her associates, who found that green leafy vegetables helped prevent macular degeneration.

Two recent studies also show that patients with high lutein levels experienced a 19% to 22% reduction in cataract incidence. The Physicians' Health Study in Boston and the Nurses' Study at Harvard look at effects of diet on eye health.

The findings of these and other studies clear the way for us to recommend the daily consumption of a multivitamin, as we would advise for our families.

But diet and supplements are only part of a successful approach in this area. We should also be telling patients to modify their lifestyles -- to stop smoking, start exercising, practice deep breathing and manage stress better, for example.

Handing out literature on these topics, including vitamins, will encourage patient compliance.

"But doctor, I already take 10 medications."

This is typical of the response you'll get when recommending supplements. Obviously, you'll need to dedicate additional chair or staff time to make these patients see that improving their vitamin and nutrition intake and lifestyle management will make them healthier and possibly even reduce their dependence on medications.

You will be empowering them. Here are some of the things you can tell your patients:

• Researchers have found that exercise, such as walking 40 minutes a day, lowers intraocular pressure 16% to 20% and increases life span as well.
• Besides helping you avoid lung disease, discontinuing smoking reduces your risk of developing such health problems as cataract and AMD.
• Avoiding obesity improves our overall health and the health of our liver and other organs, which are integral to the function of the eye. You shouldn't eat saturated fats and trans-fats contained in cookies, crackers, cheese and other processed foods that have a long shelf life. You should also avoid consuming artificial sweeteners, which are neurotoxic and contribute to dry eyes.

Suggest magnesium (500 mg tablets) at bedtime as a vasodilator to patients with circulatory problems, normal tension glaucoma and AMD. This supplement is believed to improve microperfusion of the brain and eye and won't compete for absorption when taken at bedtime or on an empty stomach. A glass of red wine once a night protects the macula and can help the elderly sleep better. (Remember that the retina gets a chance to rebuild in the dark at night, when the body also can relax.)

I also suggest that you recommend vitamins in capsule form. Evidence suggests that powder in capsules has more bioavailability, plus capsules are easier for elderly patients to digest. (For more on recommendations you can make, see "Disease-Specific Nutritional Counseling" on page 74.)

Just as important as formulation is providing the educational materials and advice so patients can make dietary recommendations and nutritional supplements part of their daily regimen. One idea is to have them create lists to keep track of what medications and supplements they're taking.

Become familiar with the vitamin stores in your community. These business owners, incidentally, will be delighted to learn of your interest and will be willing to refer customers for eye exams and ocular nutritional advice.

You should be aware of the literature which the health food store provides so that you know what your patients are reading.

Tell patients to mark on calendars when they initiate their nutritional and lifestyle changes (the exact dates), so that they can look back several months later to see if they see and feel better than they had.

They will be delighted with your level of interest in them and with your awareness of diet and nutrition. This will make them more comfortable about sharing with you.

Besides improving outcomes, taking this more holistic approach to patient care will set you apart at a time of growing competition and decreased reimbursements in eye care. It can be as healthy for your practice as it is for your patients.

This approach makes you a patient advocate, a friend to many in the community. We can always treat pathology with surgery, medications and corrective eyewear.

But helping people prevent problems is what really make us stand out.

I suggest you base your nutritional advice on types of preventable eye disease -- without losing sight of the systemic benefits good nutrition offers middle-aged and elderly patients.

Patients understand taking pills for disease, especially if they think doing this will improve their vision or make night driving easier. Here's how I approach counseling:

• To avoid cataract: I explain that drinking six glasses of water helps irrigate the crystalline lens, which has no blood supply. Increased fluid can help provide nutrition and also help with the removal of toxins, two tasks handled by the aqueous humor.
  
  Vitamin C (1,000 mg to 2,000 mg daily) and 600 mg of glutathione boosters (derived from onions, garlic, eggs, avocado) per day help minimize ultraviolet light toxicity. (Astronauts take 3,000 mg while in space.) Among glutathione boosters: N-acetylcysteine, alpha lipoic acid and Methanylolsulfanylmethane. Patients should also wear sunglasses, exercise and take an eye health multivitamin.
• To avoid glaucoma: Docosahexaenoic acid (DHA) improves circulation and may have some effect on the trabecular meshwork. It's also part of the cell membrane of every retinal receptor. I recommend 200 mg to 500 mg of DHA daily and magnesium at bedtime. New studies indicate ginkgo biloba improves blood flow to the eye, if not contraindicated.
• For patients with glaucoma and AMD: Recommend stress reduction and periodic deep breathing. Because 90% of AMD patients have the dry, slowly progressive form, they can slow progression of the disease by reducing their bright light load (UV-protective eyewear, broad-brimmed hats, wrap-around sunglasses) and building the nutrient structures in the retinas. Lutein; vitamins A, C and E; magnesium; zinc and taurine help.
• For dry eye patients: Help them evaluate systemic medications for possible causes. Drinking six glasses of water and using a bedroom humidifier will help their symptoms. I recommend artificial tears and DHA (always taken with a fat-soluble vitamin and a meal) and punctal plugs, if needed. This is a good example of mixing traditional and alternative options in your therapeutic armamentarium.

- Robert Abel, Jr., M.D.

Studies that have associated good nutrition and healthy lifestyles with better eye health include:

• East Baltimore Eye Survey.
• The Beaver Dam Eye Study.
• The Chesapeake Bay Watermen's Study
• The Eye Disease Case-Control Study (ongoing)
• The Early Treatment Diabetic Retinopathy Study (ETDRS)
• The Physicians' Health Study (ongoing)
• The Nurses' Study (ongoing)
• K The Age-Related Eye Disease Study (AREDS)

Dr. Abel, a clinical professor of ophthalmology at Thomas Jefferson University, Philadelphia, is author of the new book, The Eye Care Revolution: Prevent and Reverse Common Vision Problems, Kensington Publishing Co., N.Y., N.Y. He also co-founded the alternative medicine curriculum at Jefferson, has lectured extensively in ophthalmology and is the author of more than 100 scientific papers