A picture is worth 1,000 words. This simple truism can save you a lot of time in the exam room. When you show the patient a picture, you can drive home the preventative eye care message, benefiting the patient and establishing your role as a primary health-care provider. Patient education visuals can be used to your advantage when discussing the value of optometric initiatives such as blood pressure and diabetes screenings and InfantSee eye exams.

Another helpful graphic you should show your patients: the revised food pyramid from the departments of Agriculture and Health and Human Services. Nearly two-thirds of Americans are overweight or obese, according to the Centers for Disease Control and Prevention. By advising patients about weight maintenance with nutritional intervention, we can help them significantly improve their overall health, including their ocular health.

Hippocratic Oats
Let your food be your medicine and your medicine be your food, said Hippocrates, the father of Western medicine. In my medical center-based practice, for example, I recommend nutritional supplements to patients who need them. But, I first assess fruit, vegetable and fish consumption, often in conjunction with a dietician. As two out of three of my patients are older and overweight or obese, many require a comprehensive weight loss or maintenance and antioxidant protection program that includes diet, exercise and stress reduction.

I typically do the following:

Recommend a diet that includes 14 super foods. These are spinach, blueberries, broccoli, fish, pumpkin, yogurt, green (or black) tea, turkey, tomatoes, oatmeal, walnuts, soy, oranges and beans.1 Ophthalmologist Steven Pratt discusses these in SuperFoods Rx: Fourteen Foods That Will Change Your Life. (See Feed Your Head.)

Feed Your Head
These books provide more food for thought.

Eat, Drink, and Be Healthy: The Harvard Medical School Guide to Healthy Eating (Simon & Schuster, 2001) by Walter Willett, M.D., M.P.H., chairman of the department of nutrition at Harvards School of Public Health.3 Dr. Willett has published data on the relationship between diet and disease in large-scale, multi-ethnic populations. This is an obligatory starting point for practitioner education.

SuperFoods Rx: Fourteen Foods That Will Change Your Life (William Morrow, 2004) by Steven G. Pratt, M.D., and Kathy Matthews.1 The powerhouse foods in this book list the preferred macronutrients (proteins, fats and carbohydrates) and micronutrients (phytonutrients, carotenoids and antioxidants) that promote health.

Two handbooks The New Truth About Vitamins & Minerals (Here and Now Books, 2003) and Users Guide to Eye Health Supplements (Basic Health Publications, 2003) by health journalist Bill Sardi and a reference text Complete Guide to Vitamins, Minerals & Supplements (Fisher Books, 1988) by H. Winter Griffith discuss whats best in multivitamins.9-11

Recommend that my patients consider whether a Mediterranean-lifestyle diet, which includes fewer refined carbohydrates, can improve their well being. Most, but not all, patients respond positively to this type of diet.

Make sure that my patients safely exercise. In addition to flexibility and cardiovascular fitness, strength training to maintain and create muscle mass is particularly important for glucose tolerance and preventing catabolic tissue loss in patients past age 35.

Put the Pyramid into Practice
Use the new 2005 USDA/HHS food pyramid guidelines, available at www.mypyramid.gov, to help you discuss nutritional issues with patients. Food industry and government scientific experts designed these guidelines for Americans past age 2. The guidelines are the basis for all federal nutrition programs, including the school lunch program.

The key recommendations:
Eat fewer calories.
Make wiser food choices.
Be more active.

These guidelines are fully compatible with the National Heart, Lung, and Blood Institutes DASH (Dietary Approaches to Stop Hypertension) Eating Plan, as well as guidelines from other professional organizations to prevent heart disease, cancer and age-related eye disease.

You can send patients to the MyPyramid Web site to view an animated presentation and to create one of 12 customized dietary plans based on gender, age and level of physical activity. Ive also used this public Web site to create handouts and chairside PowerPoint presentations. Another option: Create an educational video presentation about nutrition and play it in the waiting room.

The revised food pyramid guidelines take into account all the steps involved in contributing to what the architects of the food pyramid describe as a healthier you. Indeed, the anthropometric stick figure walking up the steps of this newest pyramid represents the importance of activity level in determining daily caloric intake. One must include age and gender in the equation in order to obtain an individualized recommendation.

Steps to a Healthier You

In the diagram, the width of each stripe for the following food groups suggests how much food a person should choose from each group. (Direct patients to the MyPyramid Web site for personalized proportions.) The narrowing of each food group from bottom to top represents moderation. The wider base stands for foods that have little or no solid fats or added sugars. Select these more often. The narrower top area stands for foods that contain more added sugars and solid fats. The more active you are, the more of these foods you can allow in your diet. Some general guidelines:

Grains. For a 2,000-calorie-a-day diet, make half your grains whole and eat at least three ounces of whole-grain breads, cereals, crackers, rice or pasta every day. This reduction in grain intake from previous food guidelines acknowledges the relationship between excessive consumption of simple carbohydrates with obesity and metabolic syndrome (Syndrome X), as exemplified in such popular books as Dr. Atkins New Diet Revolution, The Zone Diet, Sugar Busters!, The Carbohydrate Addicts Diet, and The South Beach Diet. 

Vegetables. Eat more dark green vegetables, more orange veggies and more dry beans and peas. The current guidelines advise nine to 13 portions per day of fruits and vegetables (2.6 cups per day in a 2,000-calorie diet)a significant increase from the five to nine portions of fruits and vegetables recommended in 2000. This change acknowledges the need to consume more micronutrient vitamins and minerals.

Fruits. Focus on fruits as part of your nine to 13 portions per day, choosing a variety of fruits, including fresh, frozen, canned or dried. Go easy on fruit juice, which is high in sugar. As with vegetables, the amount of fruit (2.1 cups per day in a 2,000-calorie diet) has increased from the five to nine portions of fruits and vegetables recommended in 2000.

Fats and oils. Know your fats and where they come from. Take most of your fats from fish, nuts and monounsaturated vegetable oil. Meanwhile, limit saturated fats found in red meats and solid fats, such as the trans fat contained in stick margarines, shortenings and doughnuts, pastries, etc. While omega-3 fatty acids derived from flaxseed or cold-water fish reduce the risk or severity of dry eye and improve infant visual acuity and I.Q., trans fats increase the risk of cardiovascular disease and age-related macular degeneration (AMD).2

Milk. Curiously, milk is considered a food group in the United States, with emphasis on low-fat or no-fat varieties to enrich calcium in the diet. I recommend consumption of acidophilus-containing low-fat yogurt or kefir (a cultured-dairy beverage akin to liquid yogurt) to maximize any potential health benefit.1 The USDA encourages consuming the equivalent of three cups of milk or cheese per day, a notable increase in dairy consumption beyond previous recommendations. (Bear in mind that scientists have criticized this aspect of the new pyramid, citing the association between prostate cancer and high calcium consumption on the one hand and the lack of a clear relationship between hip fracture risk and dairy calcium intake on the other hand.3)

Meats and beans. Most Americans obtain plenty of protein from their diet. So, go lean on protein by choosing low-fat or lean meats and poultry. Also, vary your choices by adding more fish, beans, peas, nuts and seeds.

Even a report in the Journal of the American Medical Association recommends use of multivitamins for the entire population.4 As the average American consumes only three portions of fruits and vegetables per day, far short of the recommended nine to 13 portions per day, supplements can help make up the difference.3

We should know more than our patients about the form, dose, synergy and scientific studies supporting the use of fruits, vegetables and supplements to prevent chronic diseases of aging. When we do prescribe supplements, we need to consider what type of supplement to choose. This is a complex question because we must consider some or all of the following:
Nutritional status.
Health challenges (i.e., diabetes, smoking, neurodegenerative disease, eye disease, etc.).
Current supplements and dose.
Pharmaceutical use, which can induce further nutritional deficits beyond diet.

I generally prescribe a high-quality multivitamin/multimineral capsule (without iron) to be used in divided doses with meals (throughout the day). I adjust the dose according to the above parameters and each patients particular situation. In general, with advancing age, disease and increased pharmaceutical use, a person needs greater protection.

Exercise is a new and integral part of the revised guidelines. The guidelines recommend:

Thirty minutes of moderate to vigorous activity (i.e., walking a minimum of 1.5 to three miles/day) most days to decrease the risk of chronic disease.

Up to 60 minutes of moderate to vigorous activity most days (while not exceeding caloric intake requirements) to manage body weight.

At least 60 to 90 minutes of moderate physical activity daily (while not exceeding caloric intake requirements) to sustain weight loss.

Nutrients for Eye Health
Consistent with the 2005 food pyramid, I urge all my patients, particularly black and Hispanic patients who are at higher risk of developing eye disease and other illnesses, to increase consumption of cold-water fish and vitamin D. Sardines are ideal, as they are inexpensive, low in PCBs (polychlorinated biphenyls) and mercury, storable and accessible. Daily cod-liver oil, especially important in winter sunlight-deprived geographic areas of North America, is another great choice.

Sensible sunlight exposure (15 minutes per day for whites, five to 10 times that for people of color), to enhance vitamin D2 production within the skin, is crucial to overall health due to the myriad emerging benefits of vitamin D beyond calcium/phosphate absorption.5,6 Vitamin D production can help reduce the risk of cardiovascular disease, cancer, depression, osteoporosis, and ocular disorders such as dry eye, AMD and possibly low-tension glaucoma.

Lets Talk About Food
Todays patients want to get involved in recognizing, preventing and managing their eye health. Increasingly, patients are asking, Is there anything I can do to prevent my problem from getting worse? Let the dialogue on nutrition flow naturally in a professional manner.

For example, as with heart disease, obesity is a major risk factor for age-related cataract, macular degeneration and type 2 diabetes. If you find these ocular conditions at the slit lamp, this is the time to calculate ideal body weight (IBW) and talk about the importance of weight maintenance and exercise.

For AMD, the importance of prophylactic AREDS-derived antioxidants (vitamins C, E and beta-carotene), zinc and dietary lutein in dark green leafy vegetables is best discussed during stereoscopic evaluation of the retina when you are staging the extent of the disease for the medical chart.

Similarly, a patient complaining about dry eye-related contact lens intolerance or chronic blepharitis will often ask if there is anything else that can be done for these chronic irritating conditions. Steer the discussion toward the benefit of dietary essential fatty acids found in fish (salmon, tuna, herring or sardines) or flaxseed.

If possible, expand the conversation to include the overall systemic beneficial relationship of essential fats to heart health, macular health, cognitive function, mood, and bone and joint health. Again, the slit lamp exam provides the best opportunity to discuss the protective effect of weight reduction, fruits and vegetables, multivitamins, ascorbic acid, dietary lutein, B vitamins and sulfur-containing dietary supplements on the development of age-related cataract.

For patients at risk of advanced AMD, I recommend the supplement formulation used in the Age-Related Eye Disease Study (AREDS). Theres also compelling evidence that the carotenoid lutein not only prevents advanced AMD, but may improve visual function of most AMD patients, whether they have the advanced form of the disease or not.7 AREDS II, which is expected to begin enrollment in 2006, will evaluate the protective effects of lutein, zeaxanthin and/or omega-3 fatty acids (docosahexaenoic acid and eicopentanoic acid) against developing advanced AMD.

Meanwhile, make sure your AMD patients consume adequate amounts of spinach (one-half cup every day for AMD prevention, or double this for high-risk AMD patients), which is believed to retard Alzheimers disease as well. One exception: Patients who use the blood thinner Coumadin (warfarin, Bristol-Myers Squibb). The vitamin K in spinach interferes with warfarins effectiveness, so these patients may require an adjustment to their Coumadin level. Make sure these patients have an adequate dose of supplemental lutein alone or within their ocular or general multivitamin (i.e., one 6mg lutein capsule daily for AMD prevention, or double this for high-risk AMD patients).

Talk the Talk, Walk the Walk
A recent study questioned 153,000 adults, by telephone survey, about four health and lifestyle characteristics:8

Smoking. Some 76% of subjects didnt smoke.

BMI. Some 40% of subjects had an ideal BMI (body mass index) between 18.5 and 25.

Healthy eating. Some 23% of those surveyed ate five or more fruits and vegetables daily.

Exercise. Only 22% of respondents reported greater than 30 minutes of daily physical activity five times per week.

Significantly, only 3% of adult Americans followed all four of these basic health practices. We should all serve to strike a balance between food consumption, food choice and physical activity level. 

As primary health-care providers, we can set an example for our patients. This means following the new 2005 dietary guidelines that suggest eating a variety of foods rich in micronutrient vitamins and minerals while minimizing the ingestion of any toxic ingredient found in any particular food.

My patients report improvements in their health and vision when they pay attention to diet, weight maintenance, exercise and supplementation. We have documented these changes, published the results and presented the findings at international meetings of optometrists, ophthalmologists, other physicians and scientists.7

As primary eye-care providers working with primary-care physicians and dieticians, we should be adequately educated and prepared to evaluate body mass index, diet and risk of developing chronic age-related ocular diseases. This is no different than evaluating smoking and high blood pressure risk.

In short, follow the advice of Hippocrates: Leave your drugs in the chemists pot if you can heal the patient with food. 

Dr. Richer is chief of the optometry section/eye clinic, operative and invasive procedures, at the North Chicago V.A. Medical Center, and associate professor of family and preventive medicine at Rosalind Franklin University of Science and Medicine of the Chicago Medical School.

1. Pratt SG, Mathews K. SuperFoods Rx: Fourteen Foods That Will Change Your Life. 1st ed. New York: William Morrow, 2004.
2. Seddon JM, Cote J, Rosner B. Progression of age-related macular degeneration: association with dietary fat, transunsaturated fat, nuts, and fish intake. Arch Ophthalmol 2003 Dec;121(12): 1728-37.
3. Willett W, Skerrett PJ. Eat, Drink, and Be Healthy: The Harvard Medical School Guide to Healthy Eating. 1st ed. New York: Simon & Schuster, 2001.
4. Fletcher RH, Fairfield KM. Vitamins for chronic disease prevention in adults: clinical applications. JAMA 2002 Jun 19;287(23):3127-9.
5. Holick MF. Sunlight and vitamin D for bone health and prevention of autoimmune diseases, cancers, and cardiovascular disease. Am J Clin Nutr 2004 Dec;80(6 Suppl):1678S-88S.
6. Richardson JP. Vitamin D deficiencythe once and present epidemic. Am Fam Physician 2005 Jan 15;71(2):241-2.
7. Richer S, Stiles W, Statkute L, et al. Double-masked, placebo-controlled, randomized trial of lutein and antioxidant supplementation in the intervention of atrophic age-related macular degeneration: the Veterans LAST study (Lutein Antioxidant Supplementation Trial). Optometry 2004 Apr;75(4):216-30.
8. Reeves MJ, Rafferty AP. Healthy lifestyle characteristics among adults in the United States, 2000. Arch Intern Med 2005 Apr 25;165(8):854-7.
9. Sardi B. The New Truth About Vitamins & Minerals. 1st ed. San Dimas, Calif.: Here and Now Books, 2003.
10. Sardi B. Users Guide to Eye Health Supplements. North Bergen, N.J.: Basic Health Publications, 2003.
11. Griffith HW. Complete Guide to Vitamins, Minerals & Supplements. Tucson, Ariz.: Fisher Books, 1988.

Vol. No: 142:12Issue: 12/15/2005