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INCORPORATING

NUTRITION INTO THE

OPTOMETRIC PRACTICE

Course Title:

DISCLOSURE STATEMENTS

Please silence all mobile devices.

Advisor/consultant/speaker/editor for

(Chous): B&L, ZeaVision, Freedom Meditech, dLife-Your

Diabetic Life, Optos, Regeneron, Risk Medical

Solutions, VSP

(Reed): Alcon, B&L, MedOp, Pfizer, BioTissue

(Anshel): See subsequent slide

Lecturer: Dr. Paul Chous

Dr. Jeffrey Anshel

Dr. Kim Reed, Moderator

Counseling Diabetes Patients About Nutrition

A. Paul Chous, MA, OD, FAAO

Specializing in Diabetes Eye Care & Education

Tacoma, WA

• Advisory Board – TearLab

• Consultancies – Biosyntrx, Inc.

– Bausch + Lomb

– OmniActive Health Technologies

– Pure Encapsulations, Inc.

• Ocular Nutrition Society – Past President, Founding Director

• Editorial Advisory Board – Optometry Times

– Primary Care Optometry News

– Review of Optometry

– Optometric Office

Jeffrey R. Anshel, OD, FAAO How to Incorporate

Nutrition into the Primary Care Practice

Jeffrey Anshel, OD, FAAO

Corporate Vision Consulting

Dr. Anshel: A Day In My Practice

Nutraceutical can be defined as, “supplement that provides medical or health benefits, including the prevention and/or treatment of a specific disease."

However, the term nutraceutical as commonly used in marketing has no regulatory definition.

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Dietary Supplement: a product taken by mouth that

contains a dietary ingredient that may include vitamins,

minerals, herbs or other botanicals, amino acids and

substances such as enzymes, organ tissues, glandulars

and metabolites.

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”

“Manufacturers are not responsible for safety or effectiveness”-

Really??

FDA-regulated

products

Pre-

market

approval

Pre-market

notification Labeling Mandatory

adverse

event

reporting

GMPs Facility

registration

Advertising

(FTC or FDA)

Foods

Dietary

supplements

Drugs

June 2002 - The American Medical Association now recommends that all persons take a well formulated multiple vitamin/mineral supplement.

The recent Healthcare Professionals Impact Study found that 72% of physicians and 89% of nurses use dietary supplements. Additionally, 79% of all physicians and 82% of all nurses now recommend dietary supplements to their patients.

Sales of eye health supplements reached $419 million; up 6%.

Forty-nine percent of adults are aware of nutrients that can be helpful in promoting eye health or preventing eye health problems.

Antioxidants remain a major concept for eye health claims.

Those experiencing any eye disease or trying to reduce their risk of age-related diseases are significantly more likely to use eye health supplements.

Common Misconceptions

They are “natural”, so completely safe

They are ineffective (“only vitamins”)

They are all the same

If some is good, more is better

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A high-protein diet during middle age makes you

nearly twice as likely to die and four times more likely

to die of cancer (March 4, 2014) ◦ Morgan E. Levine, Jorge A. Suarez, Sebastian Brandhorst, et al. Low Protein Intake

Is Associated with a Major Reduction in IGF-1, Cancer, and Overall Mortality in the 65

and Younger but Not Older Population. Cell Metabolism, 2014; 19 (3): 407-41

Diets high in animal protein may help prevent

functional decline in elderly individuals (March 11,

2014) ◦ Eri Imai, Megumi Tsubota-Utsugi, Masahiro Kikuya, et al Animal Protein Intake Is

Associated with Higher-Level Functional Capacity in Elderly Adults: The Ohasama

Study. Journal of the American Geriatrics Society, 2014

“The randomized controlled trial, which has

become the gold standard for establishing the

efficacy of pharmacologic agents, is poorly suited

to the evaluation of nutritional effects, a fact that I

believe many have been reluctant to

acknowledge.”

R. Heany, MD. Editor,

American Jour Clinical Nutrition 2006

Chronic diseases have long latency and multifactorial

causation

Absence of no exposure group (only different levels of

intake)

Nutrients interact with one another; drugs designed to

work alone (on symptoms)

Nutrients act in modest beneficial ways in virtually every

body system; drugs act potentially on single targets

(RCT designed for single outcomes)

J Blumberg and B Frei, Free Radical Biol and Med 2007; 43: 1374-76.

Uncertainty in quantitative measures of food intake o Inaccurate reporting; recall bias

Uncertainty in translation of food to nutrient intake o Inaccurate food composition tables, natural variability,

processing effects, correspondence between nutrients in

certain foods

Long latent period associated with chronic disease o Inability to determine temporal cause-effect relationship

Multi-factorial environmental and genetic risk factors

for chronic disease

“We assessed fatty acid intakes by using a

validated food-frequency questionnaire and

assessed DES by using self-reports of clinically diagnosed cases.”

Relation between dietary n–3 and n–6 fatty acids and

clinically diagnosed dry eye syndrome in women

Biljana Miljanović, et al

Am Jour Clin Nutr, Vol. 82, No. 4, 887-893, October 2005

Combines the results of several studies that

address a set of related research hypotheses.

Can never follow the rules of hard science, for

example being double-blind, controlled or

proposing a way to falsify the theory in question.

It is only a statistical examination of scientific

studies, not an actual scientific study in itself.

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Be careful if the information contains:

Recommendations that promise a quick fix.

Dire warnings of danger from a single product or regimen.

Claims that sound too good to be true.

Simplistic conclusions drawn from a complex study.

Recommendations based on a single study.

Dramatic statements that are refuted by reputable scientific organizations.

Lists of "good" and "bad" foods.

Recommendations made to help sell a product.

Recommendations based on studies published without peer review.

Recommendations from studies that ignore differences among individuals

or groups.

Reference: The Food and Nutrition Science Alliance

“Flaxseed oil may be an effective anti-

inflammatory nutritional therapy alternative to

long-term antibiotics” Ken Nischal, Co-author

Dec. 2007 Ophthalmology

“Flaxseed oil was not used as the primary treatment. It was used

only as a maintenance treatment after lid margin disease was

controlled”

“Primary treatment consisted of modified lid hygiene, topical

antibiotics and steroids. Systemic oral antibiotics also were

administered”

CONCLUSION: “Flaxseed oil …is a promising new addition in the

management of blepharitis”

Chocolate Linked to Improved

Brain Performance

“Cocoa flavanols found in dark chocolate called epicatechins can

improve the memories of snails, according to researchers.”

J. Exp. Biology 215, 3566-3576. (2012)

Fruston, L, et al.

Whole Foods Market commits to full GMO transparency

Company supports consumer’s right to know by setting five-year deadline for labeling GMOs

Whole Foods Market announced today at Natural Products Expo West that, by 2018, all products in its U.S. and Canadian stores1 must be labeled to indicate if they contain genetically modified organisms (GMOs)2. Whole Foods

Market is the first national grocery chain to set a deadline for full GMO transparency.

“We are putting a stake in the ground on GMO labeling to support the consumer’s right to know,” said Walter Robb, co-

CEO of Whole Foods Market. “The prevalence of GMOs in the U.S. paired with nonexistent mandatory labeling makes

it very difficult for retailers to source non-GMO options and for consumers to choose non-GMO products. Accordingly,

we are stepping up our support of certified organic agriculture, where GMOs are not allowed, and we are working

together with our supplier partners to grow our non-GMO supply chain to ensure we can continue to provide these choices in the future.”

- by 2018

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Tobacco

High blood pressure

Overweight/obesity

Physical inactivity

High blood glucose levels

High LDL cholesterol

High levels of dietary salt

Low omega-3 levels

High levels of trans fatty acids

Alcohol use

Low levels of fruit and vegetables

Low levels of polyunsaturated fatty acids.

The Preventable Causes of Death in the United States:

Comparative Risk Assessment of Dietary, Lifestyle, and

Metabolic Risk Factors Goodarz Danaei, et al

(# chemicals in each cigarette) 7000

About 60 studies link obesity with chronic eye

disease

Nutritional counseling fulfills your role as a primary

healthcare provider

Patients have the ultimate responsibility in their

healthcare; yours is to bring it to their attention!

Dr. Chous: A Day in My Practice

• 10 comprehensive eye examinations

• 4 office calls (IOP checks, VF exams, OCT etc.)

• 90% patients with diabetes (80% T2DM)

• Adjacent to a 5-doctor, 4 ARNP-CDE endocrine specialty practice

• 50% of my patients are co-managed with endocrinology; 70% are referred by endocrinology or PCPs

My Patients • A majority has A1c < 7%

– But about 1/4 have Ac > 8%

– A majority takes metformin and statins

– A majority is vitamin D insufficient

• A majority has HTN, dyslipidemia and hCVD risk

• A majority is overweight or obese (1/3 has OSAS)

• A majority has NAFLD

• 1/3 have some degree of DR and/or DME

• 1/6 have some degree of AMD

• ½ have some form of ocular surface disease

My Basic Principles for Nutritional Counseling

• Giving patients patients SOME guidance is better then giving them NO guidance

• It doesn’t have to take a lot of time

• You know far more about nutrition and eye disease than any of your patients

A Few Simple Questions • Preface with “The foods we eat have a major

impact on our eye health, so I’d like to ask you….”

• What are your favorite foods?

• How often do you eat these foods?

• On a typical day, how many types of fruits & vegetables do you eat?

• Do you eat fish very often? How many times per week/month/year?

• How much soda do you drink per day/week?

• Do you take any supplements?

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Don’t Deride Multivitamins

• There is evidence that MVMs improve common nutritional deficiencies, and safeguard animals from chronic marginal deficits that contribute to chromosomal breaks & chronic diseases of aging that occur over years/decades

Low micronutrient intake may accelerate the degenerative diseases of aging through allocation of scarce micronutrients by triage

Proc Natl Acad Sci U S A. Nov 21, 2006; 103(47): 17589–17594

Bruce Ames, PhD – UC Berkeley, National Medal of Science Recipient

Nutrition

• The best intake is through diet/food – Not always realistic:

– Average American gets only 2mg Lutein – Leading antioxidant source for the average

American is coffee – French fries account for 25% of all vegetable

intake in US – Importance of healthy lifestyle

• But only 3% of Americans follow 4 basic health practices

Nonsmoking (76 %) BMI 18.5 – 25 (40%) 5 or more F &V daily (23%) > 30 minutes physical activity 5 times

per week (22%)

Assessing Nutritional Status

• Common nutrient deficiencies seen in CVD, AMD, diabetes include:

– Zinc

– Magnesium

– Vitamin D

– Vitamin C

– B vitamins – especially B12, folate, thiamin

– Lutein

– Zeaxanthin

Int J Vitam Nutr Res. 1991;61(4):328-33

J Ayub Med Coll Abbottabad. 2003 Jan-Mar;15(1):54-7

Benfotiamine

• Normalized activity in polyol, hexosamine, AGE, pathways in T1DM

• Totally prevented diabetic retinopathy in an animal model

• Normalized 4 major pathways of biochemical insult due to hyperglycemia (polyol, PKC, hexosamine, AGE)

• Blocks pericyte apoptosis due to hyperglycemia

Diabetologia. 2008 Oct;51(10): 1930-2

Nat Med. 2003 Mar;9(3): 294-9

Diabetes Metab Res Rev. 2009 Oct;25(7):647-56

Fat Soluble Thiamin (vit B1) Analog

Hyperglycemia hMitochondrial ROS

Hexosamine Flux

AGEs PKC-b Polyol

Oxidative Stress

Benfotiamine

Easy Lab Tests that Will Truly Help

• Serum 25-OH vitamin D

• Serum B-12 (especially for patients on metformin)

• 1,5-anhihydroglucitol (Glycomark®) for post-prandial spikes

• hsCRP (predicts CSME)

• A1c

• Measure macular pigment

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Consider establishing an account with a local clinical lab PacLab Qwest Diagnostics LabCorp

The Importance of Preventing Blood Glucose Spikes

AKA “Post-prandial Hyperglycemia” or “Glycemic excursions”

DCCT:

Retinopathy developed more often in pts receiving “conventional Tx” at HbA1c Levels equal to those in the “intensive Tx” group

New Evidence Spikes Matter

1,5-Anhydroglucitol is a serum glucose

metabolite reduced by urinary excretion when

serum glucose > 180 mg/dl

Low blood 1,5-AG reflects 5PPG excursions

Lower levels of serum 1,5-AG increase

the risk of DR nearly 3x in T2DM patients,

including those with HbA1c levels < 8%

Diabet Med. 2012 Sep;29(9):1184-90

Mean MPOD within 2° of Fovea

• No diabetes: 0.29 DU

• Diabetes sans retinopathy: 0.22 DU • Diabetes with mild NPDR: 0.14 DU

Lima VC, Rosen RB. Invest Ophthalmol Vis

Sci 2010 Nov;51(11):5840-5.

Hemoblobin A1c..relevance to OD’s

• Critical to disease control and prevention of complications

• 2/3 of patients are unaware of their last A1c result

• In office testing

– www.a1cnow.com

• POC A1c more powerful1

1. Diabetes care 30:713-715, March 2007.

A1c is a “Quality of Life” Number A1cNow+ Disposable, Multi-test System

No calibration required

Costs $10-$12 per test Current reimbursement is $30-$50

The A1cNow+ is a new A1c monitor that can be used 10 times and then it is disposed of.

· Requires only 5 microliters of blood · Multi-test monitors available in 10-test or 20- test versions. · Use all-in-one sampling device. · Large easy to read display. · No capital equipment needed · No calibration, no daily control. · No Maintenance

· Billable to CPT Code 83037QW

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Best Way To Prevent Diabetic Retinopathy??

Don’t Get Diabetes!!!

Practical Tips To Avoid Diabetes

Exercise 30 minutes each day (soon after waking)

Eat a low GI Mediterranean type diet

Eat breakfast

Eat a variety of fruits and vegetables and more vegetables

Minimize processed meats

Drink coffee or tea

Sleep > 6 hours but < 9 hours per night

Get your serum vitamin D checked

Breast feed *Turn down the thermostat

* Live away from smog

Counseling Overweight & Obese Patients

• Ask for permission to discuss weight status as it relates to increased risk of eye disease and poorer visual outcomes

• Be Respectful - Remember the “Golden Rule”

– How Would You Want to be Treated?

• Surveys of overweight/obese patients show the

words “fat” and “obese” are offensive – the term excess “excess weight” is preferred

Discussing Epigenetics With Patients

• We can’t change the genes we inherit from our parents

• We can often change whether or not the good and bad genes are ‘turned on’ by leading a healthy lifestyle

‘Diabetes Overwhelmus’

• Many patients feel overwhelmed by their diagnosis, complexity of multifaceted treatment, and magnitude of information (misinformation)

You Are Not Alone……

• Such stress is also common in many chronic diseases, including eye diseases –AMD

–Glaucoma

–Diabetic retinopathy

–Low Vision

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• Chronic disease is associated with higher rates of both situational & chronic depression

• It is useful for HCPs to assess degree of both psychosocial stress and efficacy

– Is the patient overwhelmed?

– How well is the patient adhering to treatment and achieving metabolic goals?

Quick Assessment

• On a 5-Point Scale, rate how you’re doing with your diabetes:

– I am feeling overwhelmed by the demands of living with diabetes. 1 2 3 4 5

– I am feeling that I am often failing with my diabetes regimen. 1 2 3 4 5

• Higher scores suggest a need for stress reduction techniques/professional counseling, diabetes education, or BOTH

Ann Fam Med. May 2008; 6(3): 246–252.

Practical Tips or Reducing Stress 1. Set goals: write them down 2. Identify situations that cause stress in your life:

Identifying these will help you know what you want & need. 3. Ask for help from your doctors, family & friends &

coworkers 4. Exercise more: exercise releases ‘feel-good hormones’ like

endorphins and serotonin. These improve your ability to cope with diabetes, lower your blood sugar, and relax.

5. Practice daily relaxation. Learn meditation techniques you can do at home (such as deep breathing for 10 minutes, three times a day), or join yoga or tai chi classes. (try Andrew Weil’s 4-7-8 Circle Breathing technique)

` 6. Eat a healthier diet. Some foods can exacerbate stress, such as sugar and caffeine, so try to eliminate or limit them. Plus, better nutrition naturally helps to control your blood glucose levels.

HeartMath® Inner Balance app

Practical Tips for Good Blood Glucose Control

• Eat a lower glycemic index, Mediterranean-type or Paleolithic diet that contains a variety of vegetables and whole fruits (not fruit juices). Diets like this have been proven to lower blood glucose levels.

• Substitute water or unsweetened tea for soda pop and avoid foods and beverages sweetened with high fructose corn syrup.

• Limit your consumption of packaged snack foods (crackers, cookies, even ‘sugar-free’ snacks) that contain lots of refined carbohydrates that boost blood sugar levels.

• Eat smaller, more frequent meals to prevent blood sugar spikes. Source: A. Paul Chous, OD, FAAO

• Make sure vegetables fill at least half of your plate at meals.

• Eat smaller portion sizes and try to limit total carbohydrate content of any big meal to 30 grams or less of carbohydrate (look at food labels to determine carbohydrate content and portion size per serving).

• Eat more slowly – this gives your stomach more time to feel full without over-eating; try putting your utensil down while you chew your food and don’t pick it back up until you have thoroughly chewed and swallowed the last bite.

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H2O or

Tea

• Get regular exercise – at least 30 minutes of moderate intensity physical activity each day. Exercise, even small amounts, dramatically improves insulin sensitivity and lowers blood glucose levels.

• A good way to get exercise is to buy a pedometer and walk 8-10 thousand steps each day.

• Make sure you take your prescribed diabetes medications, on time, every time.

• If your blood glucose levels & A1c test remain higher than your doctor’s recommended target after taking the above steps, ask about getting a continuous glucose monitoring system (CGMS) to help determine the best treatment plan.

• Try taking 2 TBSP of apple cider vinegar before meals – studies show this limits post-meal blood sugar levels.

Vinegar Battles Glucose Spikes

Vinegar improves insulin sensitivity in IR subjects Diabetes Care. 2004 Jan;27(1):281-2

2 Tbsp vinegar consumed before a 75g CHO meal prevented post-prandial glucose spikes in pts with T1DM and reduced AUC BG by 20%

Acetic acid delays gastric emptying and enhances glycogen repletion

Diabetes Care. 2010 Feb;33(2):e27

More on Vinegar

Lowers post-meal hyperglycemia after a high GI meal by 38% in T2DM

Reduces Fasting blood sugar 4-6%

Doesn’t effect OGTT in T2DM pts

May erode tooth enamel!

Eur J Clin Nutr. 2010 Jul;64(7):727-32

Diabetes Care. 2007 Nov;30(11):2814-5

J Diabetes Complications. 2012 Sep-Oct;26(5):460-1

WHY?

Dietary Strategies

• Reduce & “diffuse” carbohydrate intake to control blood glucose

• Reduce caloric intake to decrease visceral fat (VAT), insulin resistance (IR) & dyslipidemia

• Portion Size is both the most important and under-appreciated value on food labels

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Portion Control - Obstacles Metabolic abnormalities of DM suppress

normal inhibition of appetite Hypothalamic satiety receptors are blunted by insulin resistance (IR)

Hypoglycemia triggers insatiable appetite by activating the endocannabinoid system

The Hypothalamus Mediates Hunger

& Satiety

There is a Biological Basis for Over Eating

In Diabetes & Metabolic Syndrome

My A1c is “Good”

• 2/3 of DM patients don’t know what A1c is or means

• A1c > 5.8% is linked to all-cause mortality in patients with and without diabetes

Diabetes Care. 2011 Jun;34(6):1355-61

Metabolic Control in US Diabetes Patients

60% have A1c > 7%

Up to 70% of patients with diabetes have blood pressure levels above target J Gen Intern Med. 2008

May;23(5):588-94

Am J Manag Care. 2013 Feb;19(2):104-12 J Clin Hypertens 2010 Oct;12(10):826-32.

www.RetinaRisk.com

• Algorithm recently validated in a

multi-cultural UK cohort (> 15,000)

• Launched at AOA Convention, San

Diego, 2013

• Free 30 day trial – check it out

A Reality Check

Hypoglycemia is disabling & can quickly incapacitate (even kill) patients

Many patients opt for chronic hyperglycemia because it has far less impact on function, and the consequences are distant in time

We must correct time myopia as well as refractive myopia

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Good Control Does NOT Eliminate Risk of Severe DR 10 year risk of PDR and/or CSME

in a newly Dx patient with A1c = 6.5% and BP = 120/80 is nearly 4%

With mild NPDR the 10 yr risk is 8.4%

Diabetologia. 2011 Oct;54(10):2525-32

Patient JK – 62 YO MALE DX WITH T2DM X 6

YEARS AND A1C < 6.2% AND BP < 125/84 SINCE

DIAGNOSIS

Can we can use nutritional supplements to bite the hands that Feed Diabetic Retinopathy?

“It may be time to develop, test and educate ECPs & the public about an AREDS type multi-component supplement for patients with diabetes and diabetic retinopathy”

Beyond AREDS: is there a place for antioxidant therapy in the prevention/treatment of eye disease? Kowluru RA, Zhong Q. Invest Ophthalmol Vis Sci. 2011 Nov 7;52(12):8665-71

Diabetes & DR Affect Visual Function Snellen visual acuity is a 150+ yr old test

that does not always reflect real world visual function

DM/DR also impair: color perception, contrast sensitivity, visual field sensitivity

Graefes Arch Clin Exp Ophthalmol. 2012 Dec;250(12):

Diabet Med. 2011 Jul;28(7):865-71 Acta Opthalmol 2005; 82(5):574-80 Graefes Arch Clin Exp Ophthalmol. 2001 Sep;239(9):643-8 BJO 1996;80: 209-13 IOVS 1997; 38(9): 1819-24 Diabetes Care 1992; 15(5):620-25 Graefes Arch Clin Exp Ophthalmol.1996 May;234(5):300-5

6 month placebo-controlled RCCT of adults with T1DM or T2DM > 5 years

No DR (2:1) and mild-moderate NPDR (1:1)

Daily use of a multi-component nutritional supplement (non-provit. A carotenoids, D, C, E, curcumin, benfotiamine, Pycnogenol, lipoic acid, NAC, resveratrol, green tea, O-3 FAs, CoQ10)

Pre- and post- analysis of CSF, MPOD, color vis., macular perimetry, OCT, A1c, lipids, 25(OH) vit. D, TNF-a, hsCRP

Diabetes Visual Function Supplement Study

(DiVFuSS)

ClinicalTrials.gov Identifier: NCT01646047

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Animal Model of DR

• DiVFuSS formula blocked early mitochondrial damage in rats

• DiVFuSS formula blocked retinal capillary apoptosis underlying DR

• DiVFuSS formula improved b-wave ERG (retinal function)

• No affect on blood glucose

Nutr Metab (Lond). 2014 Jan 30;11(1):8

Analysis of 67 subjects to complete the trial in August 2014

DiVFuSS Unmasked

Submitted to British Journal of Ophthalmology 2015

DiVFuSS Unmasked Data Δ from baseline Suppl versus Plac p-Value

Contrast: +28% -15% 0.008

Color Error Score: -42% -4% 0.002

5-2 MD: +1.3 dB +0.11 dB <0.0001

hsCRP: -60% -11% 0.01

HbA1c: -1.7% +1.7% 0.06

NFL & RT unchanged in both groups 0.79

DPNSS -46%% +8% 0.002

Key Education Points

• Diabetes is a leading cause of irreversible

vision loss

– All patients with diabetes are at higher risk of

vision loss, even those with gret diabetes

control

• DR is caused by a number of cumulative

and overlapping biochemical pathways

• DiVFuSS ingredients interfere with each of

these pathways

• In a clinical trial, the DiVFuSS formula

improved vision in people with diabetes

• In an animal study, the formula prevented

diabetic retinopathy

• Taking this formula provides an additional

strategy for promoting eye health and

normal vision in diabetes patients

INDEPENDENT of blood glucose control

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What to recommend?

Supplements for Bob G

1. Dr. Linus Pauling super Multi-Vitamins: 2 Daily

2. Chewable Vitamin C: 100mg 1 daily

3. Moducare (plant sterols): 2 twice daily

4. L-Lysine (500 mg): 1 twice daily

5. Liver Protec: 1 twice daily (d-alpha tocopheryl succinate, silymarin,

quercetin di-hydrate, Alpha-lipoic acid, calcium D-glucarate

6. Vasotensin: 2 twice daily

7. Cal Apatite with Magnesium: 1 in AM, 2 in PM

8. Rutin 50mg: 1 twice daily

9. Tumeric: 1 tablet, twice daily

10.CoQ10; 100mg: 1 twice daily

11.Folic Acid; 800 mcg: 1 pill twice daily

12.Policosanol; 10 mg: 1 pill twice daily

13.Dr. Bernard Jensen’s Cleanse It (colon cleansing)

14.Glucosomine: 2 pills; twice daily

Vitamin A (20 % as beta carotene) 6,000 IU 120 % Vitamin C 64 mg 105 % (80 mg of

patented Ester C, Zinc ascorbate) Vitamin D (ergocalciferol) 600 IU 150 % Vitamin E (d-

alpha tocopheryl) 33 IU 110 % Vitamin K (phytonadione) 20 mcg 25 % Thiamine (thiamin

mononitrate) 20 mg 1330 % Riboflavin 20 mg 1175 % Niacin (niacinamide) 25 mg 125 %

Vitamin B6 (pyridoxin HCL) 12 mg 600 % Folate 800 mcg 200 % Vitamin B12

(cyanocobalamin) 100 mcg 1660 % Biotin 60 mcg 20 % Pantothenic Acid (calcium

pantothenate) 30 mg 300 % Calcium (dicalcium phosphate) 120 mg 12 % Iron (ferrous

fumarate) 8 mg 44 % Iodine (potassium iodine) 300 mcg 200 % Magnesium (magnesium

oxide) 50 mg 12 % Zinc (zinc ascorbate) 15 mg 100 % Selenium (selenium aspartate) 40

mcg 55 % Copper (copper oxide) 4 mg 200 % Manganese (manganese sulfate) 3 mg 150

% Chromemate (chromium polynicotinate) 14 mcg 12 % Molybdenum (sodium

molybdenum) 50 mcg 65 % Guarana extract (seed) 175 mg

Alfalfa (leaf) 30 mg ** Chlorella (plant) 30 mg ** Royal Jelly 25 mg ** Spirulina (plant) 25

mg ** Echinacea Purpurea (root) 20 mg ** Vanadium (sodium metavanadate) 20 mcg **

Silicon (silicon dioxide) 20 mcg ** Nickel (nickelous sulfate) 2.5 mcg ** Proprietory Blend

of Phyto-Herbal Complex 32 mg Ginko Biloba (leaf) ** Spirulina (plant) ** Garlic (bulb) **

Apple powder (fruit) ** Broccoli powder (vegetable) ** Carrot powder (vegetable) **

Orange powder (fruit) ** Activin Grape seed extract (seed) **

Do they provide current science about their

products?

Is their manufacturing third-party GMP certified?

Do they offer training for the doctor AND staff?

Do they have brochures and displays for your front

office?

Do they offer incentives?

Do they offer reasonable prices?

Do they have a money-back guarantee?

Should be easy to digest - no hard-pressed pills

Good blend and balance of nutrients

Formulated around the very latest science in nutritional medicine

Designed to slow the progression of chronic degenerative disease, including diseases of the eye.

Efficacious amounts of properly balanced fat-soluble vitamins, particularly as it relates to the latest vitamin A and vitamin D research.

Vitamin A should be Retinol, not beta-carotene.

Contain potent amounts of the full-spectrum of B

vitamins for the proper maintenance of homocysteine,

specifically B6, B12 and folic acid.

Contain 400 IUs of the complete spectrum of Vitamin E

with a balanced mixture of both natural d-alpha

tocopherol and mixed tocotrienol oils containing gamma

and delta tocotrienols.

Supplemental iron has been linked to heart disease, so it

should be iron-free.

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Contain the full army of “job-specific” antioxidants that both prevent free-radical damage, as well as neutralize the effects of previous oxidative damage

Contain efficacious amounts of eye-specific carotenoids: lutein and pure zeaxanthin; and properly balanced amounts of beta-carotene to ensure proper xanthophyll transport to the retina.

Contain the spectrum of minerals in their most bioavailable form to ensure proper cellular bioelectrical and enzymatic response.

Calcium-400-1200 mg/day

Magnesium-200-600 mg/day

Boron-2 mg/day

Zinc 15-40 mg/day

Selenium- 75-200 mcg/day

Copper-1-2 mg/day

Chloride-1.7-5g/day

Manganese -5mg/day

Chromium-150

mcg/day

Molybdenum-100-200

mcg/day

Sodium-500-1500

mg/day

Potassium-2000

mg/day

Vanadium-150-200

mcg/day

MnSOD (zinc, copper and manganese)

is vital for intracellular clean up

PROS CONS

High Potencies No Co-factors

Smaller Dosages Low Bioavailability

Inexpensive Poor Assimilation

Digestive Discomfort

Can Deplete Other

Nutrients

“Here are a few samples- see which one you

like the best”.

“Just go to the drug store and pick up some

vitamins”……..

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“I think I got all the vitamins the eye doctor told me to get…”

“Just take some Fish Oil!”

Labs- are they reputable and accurate?

◦ Spectracell

◦ Metametrix

◦ Quest

◦ Direct Labs

◦ Etc….

Nutrition questionnaire- who will evaluate?

MPOD- what are you measuring?

Densitometer (MacuHealth)

Quantifeye (Zeavision)

Heterochromic flicker photometry

Heterochromic flicker photometry

Self-contained unit Self-contained unit

3-5 minutes per pt. 2-3 minutes per pt.

Alternate wavelength stimulus presented

Alternate wavelength stimulus presented

$23,000. $17,000.

Nutrition: MacuHealth Nutrition: EyePromise

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Courtesy of

The Dietary Supplement Label Database (DSLD) is a joint

project of the National Institutes of Health (NIH) Office of

Dietary Supplements (ODS) and National Library of

Medicine (NLM). The DSLD contains the full label contents

from a sample of dietary supplement products marketed in

the U.S.

All information is obtained from the manufacturers' labels.

http://dsld.nlm.nih.gov/dsld/

Centrum Silver Ingredients:

Serving Size: 1 Tablet

Each Tablet Contains - % Daily Value:

Vitamin A 3500 IU (29% as Beta Carotene) - 70%,

Vitamin C 60 mg - 100%,

Vitamin D 400 IU - 100%,

Vitamin E 45 IU - 100%,

Vitamin K 10 mcg - 13%,

Thiamin 1.5 mg - 100%,

Riboflavin 1.7 mg - 100%,

Niacin 20 mg - 100%,

Vitamin B6 3 mg - 150%,

Folic Acid 400 mcg - 100%,

Vitamin B12 25 mcg - 417%,

Biotin 30 mcg - 10%,

Pantothenic Acid 10 mg - 100%,

Calcium 200 mg - 20%,

Phosphorus 48 mg - 5%,

Iodine 150 mcg - 100%,

Magnesium 100 mg - 25%,

Zinc 15 mg - 100%,

Selenium 20 mcg - 29%,

Copper 2 mg - 100%,

Manganese 2 mg - 100%,

Chromium 150 mcg - 125%,

Molybdenum 75 mcg - 100%,

Chloride 72 mg - 2%,

Potassium 80 mg - 2%,

Boron 150 mcg - *, Nickel 5 mcg - *, Silicon 2 mg -

*, Vanadium 10 mcg - *, Lutein 250 mcg - *,

Lycopene 300 mcg - *.

*Daily Value not established

Dibasic Calcium Phosphate, Calcium

Carbonate, Potassium Chloride,

Microcrystalline Cellulose, Ascorbic Acid (Vit.

C), Magnesium Oxide, dl-Alpha-Tocopheryl

Acetate (Vit. E), Modified Food Starch.

Contains < 2%: Acacia, Anhydrous Citric

Acid, Ascorbyl Palmitate, Beta-Carotene,

Biotin, Boric Acid, BHT, Calcium

Pantothenate, Calcium Stearate,

Cholecalciferol (Vit. D3), Chromium

Picolinate, Corn Starch, Crospovidone,

Cupric Sulfate, Cyanocobalamin (Vit. B12),

dl-Alpha-Tocopherol, FD&C Blue No. 2

Aluminum Lake, FD&C Red No. 40

Aluminum Lake, FD&C Yellow No. 6

Aluminum Lake, Folic Acid, Gelatin,

Hydrogenated Palm Oil, Hypromellose,

Lutein, Lycopene, Manganese Sulfate,

Medium-Chain Triglycerides, Niacinamide,

Nickelous Sulfate, Phytonadione (Vit. K),

Polyethylene Glycol, Polyvinyl Alcohol,

Potassium Iodide, Pregelatinized Corn

Starch, Pyridoxine Hydrochloride (Vit. B6),

Riboflavin (Vit. B2), Silicon Dioxide, Sodium

Ascorbate, Sodium Benzoate, Sodium

Borate, Sodium Citrate, Sodium

Metavanadate, Sodium Molybdate, Sodium

Selenate, Sorbic Acid, Sucrose, Talc,

Thiamine Mononitrate (Vit. B1), Titanium

Dioxide, Tricalcium Phosphate, Vitamin A

Acetate (Vit. A), Zinc Oxide.

May also contain < 2%: Maltodextrin,

Sodium Aluminum Silicate

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Addressing the patient’s concerns

Enhanced understanding of the patient’s overall health

Brings patients back to the office frequently

Better from you than the health food store clerk!

Enhance your reputation

Recommend- to present as worthy of acceptance or

trial

Prescribe- to designate or order the use of as a

remedy; used on controlled substances

Retail- the sale of commodities in small quantities to

the ultimate consumer

1. Diagnose the problem

2. Discuss with patient

3. Consider treatment options (including alternatives)

4. Make your recommendation

5. Give them a brochure of your product(s)

6. Options for purchase: a. From your office

i. Immediate- take product

ii. Consider at home- make note; inform front desk (routing slip)

b. Order direct from company (phone or Web)

If product is purchased: ◦ “Do you have any questions about the product?”

◦ “How do you feel it’s working so far?”

◦ “Do you notice any unexpected symptoms?”

If product not purchased: ◦ “The doctor asked to see if you’ve started taking the

supplement he recommended (assumes they got it on-

line)

◦ If not, why not?

Follow ups increase business about 50%!

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_____(Supplement Name): take 2 capsules

twice daily with morning and evening meal

_____(Supplement Name): take 3 capsules

twice daily with morning and evening meal

"You cannot include in medical expenses the cost of nutritional supplements, vitamins, herbal supplements, “natural medicines,” etc. unless they are recommended by a medical practitioner as treatment for a specific medical condition diagnosed by a physician. Otherwise, these items are taken to maintain your ordinary good health, and are not for medical care."

Being respectful (85%)

Listening carefully to health concerns (84%)

Being easy to talk to (84%)

Take their concerns seriously (83%)

Willing to spend enough time (81%)

Good medical judgment (80%)

Harris Interactive Poll, 2005

Goal Setting – be an advocate & be specific

Take these supplements and bring back the empty bottles next time for 30% off your next eyeglass purchase

Let’s get you a pedometer and walk 10,000 steps/day every day until your next appointment

Let’s increase your MPOD to 0.40

Let’s get your A1c under 7% by next visit

Let’s work on losing 5% of your current weight for next visit

If you want to quit smoking, I will help you

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My Experience

Scare tactics generally don’t work, if at all, until patients have lost something

Scare tactics and threats aren’t conducive to good relationships

Building a relationship works

A Simple Strategy

• Ask patients to write down your recommendations (more likely to remember)

• Ask patients the one thing they would like to improve upon – enter that in the chart (get ‘buy-in’)

• Ask patients about that one thing at follow-up (a big or small step is better than no step at all)

A. Paul Chous, O.D.

Practical Tips to Avoid Asphyxiation

Drink liquid first to moisten mouth

Coat large pills/capsules with olive oil

Keep chin tucked down to close off the pharynx (opposite of CPR!)

Take smaller supplements or liquid supplements if possible

Lose the Word “Diabetic”

• Most patients do not want to be known AS THEIR Diagnosis

• Why don’t we call patients “macular degenerates”?

• Identifying people as their diagnoses is existentially diminutive – substituting a part of a human being for the whole human being

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Counseling Patients

Talk about nutrition with your patients who have or are at risk for/from eye disease

Discuss Prevention with everyone

Ask for permission to discuss weight status as it relates to risk of retinal disease

Measure & Improve Visual Function

Criticize behaviors, not the patient

Make specific recommendations,

set goals and use handouts

Focusing on Nutrition Education

www.ocularnutritionsociety.org