Article Date: 12/1/2004

"It's Irresponsible Not to Educate Patients"

Dr. Stuart Richer explains why optometrists must integrate nutrition into their practices.

Nutrition shouldn't be considered a specialized area of optometry, says Stuart Richer, O.D., Ph.D, F.A.A.O.

As a primary care provider, he argues that nutrition is an essential component of every eye examination, just as important as checking blood pressure.

In this interview, Dr. Richer, a recognized leader in the area of nutrition and eye care, explains why optometrists must integrate the study of nutrition into their practices.

Expanding the O.D. role

OM: Do you actively recommend/prescribe nutritional supplements to your patients?

DR. RICHER: Yes, but first I assess fruit, vegetable and fish consumption, often with a nutritionist, and I also make sure that my patient is exercising. I'm in a medical center HMO-type practice, so obtaining a workup from a registered dietician requires initiating a consult. It's more problematic for the private practitioner, but such cooperation with a dietician or nutritionist might pay off handsomely in terms of patient referrals. In addition to flexibility and cardiovascular fitness, strength training to maintain/create muscle mass is particularly important for glucose tolerance and for preventing catabolic tissue loss in patients beyond 35 years of age.

As two-thirds of my patients are overweight or obese and chronologically advanced in age, patients first require a comprehensive weight maintenance and antioxidant protection program that includes diet, exercise and stress reduction. I always calculate and discuss body mass index (BMI) and, if high (30 or above), relate the association of obesity with cardiovascular disease, diabetes and eye diseases.

Regardless, I recommend a diet of superfoods such as spinach, blueberries, pumpkin, yogurt, green tea, etc., as ophthalmologist Steven Pratt, M.D., and Kathy Matthews discuss in their book, Superfoods Rx: Fourteen Foods That Will Change Your Life (Harper Collins 2003). I also recommend that my patients assess whether a lower refined carbohydrate (Mediterranean diet lifestyle) improves their well being. Most, but not all, patients respond positively to this type of diet, as Walter Willett, M.D. and P.J. Skerritt discuss in their paperback book Eat, Drink and Be Healthy: The Harvard Medical School Guide to Healthy Eating.

OM: What kind of nutritional supplements do you prescribe to your patients?

DR. RICHER: This is a complex question, as it engenders some or all of the following issues:

In general, I'll prescribe a high-quality multiple component multivitamin/multimineral capsule (without iron unless the patient is premenopausal or anemic) in divided doses with meals (throughout the day). I adjust the dose according to the above parameters and particular situation.

Generally speaking, with advancing age, disease and pharmaceutical use, there is a need for more protection. Several "all-in-one" comprehensive supplements are available from,, and other manufacturers. Again, I adjust the dose based on the above factors, increasing the protection with age.

OM: For what conditions do you recommend/prescribe nutritional supplements?

DR. RICHER: I urge all of my patients -- particularly African Americans and Hispanics -- to increase cold water fish/vitamin D consumption. Sardines are ideal, as they're inexpensive, low in PCB and mercury, storable and accessible. Daily codliver oil, especially important in winter sunlight-deprived geographic areas of the United States and Canada, is another great choice. Sensible sunlight exposure (15 minutes every day for Caucasians and five to 10 times that for people of color) to enhance vitamin D2 production from the skin is important for overall health. This is going to benefit everyone in terms of reducing cardiovascular risk and cancer, depression, osteoporosis and eye disorders such as dry eye, macular degeneration and possibly low-tension glaucoma. Michael Holick, M.D., Ph.D. has written a nice review in "Vitamin D: Importance in the Prevention of Cancers, Type-I Diabetes, Heart Disease and Osteoporosis," which appears in the March 2004 issue of the American Journal of Clinical Nutrition.

The Journal of the American Medical Association recommends even pabulum (recommended daily allowance [RDA] based) multivitamins for the entire population. Even once-a-day multivitamins have been shown to reduce the prevalence of cataracts in a large-scale study of physician patients.

I use an Age-Related Eye Disease Study (AREDS)-type formulation for patients who are at risk of developing advanced age-related macular degeneration (AMD) based on clearly defined retinoscopic staging. It's projected that more than 300,000 patients who have AMD will avoid the development of the devastating effects of this disease in a five-year period by using high-dose vitamin E, C, zinc and beta carotene.

There's also compelling evidence that 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. AREDS II is going to evaluate the protective effects of lutein and zeaxanthin against developing advanced disease.

In the meantime, I make sure my patients have adequate spinach consumption (it prevents Alzheimer's disease as well) or, if the they're on the blood thinner warfarin (Coumadin), I make sure they have 6 mg to 10 mg supplemental lutein alone in their comprehensive foundation multivitamin or within their specialty ocular vitamin.

Patient perspectives

OM: How do patients react to you, an optometrist, prescribing something so nontraditional?

DR. RICHER: They thank me. We are primary providers, so evaluating diet, BMI status, exercise and multivitamin use is analogous to evaluating smoking and high blood pressure.

OM: Do you ever ask patients whether they take any supplements on their own?

DR. RICHER: Always -- it's part of my workup. Occasionally, a patient decides to take a high-dose, single nutrient such as single isomer vitamin E for cardiovascular disease or high-dose calcium for bone health (without beneficial adjuvants such as magnesium, vitamin D, etc.), solely on a media report. Such patients merit more specific counseling to optimize food and supplement choice.

While physicians will sometimes prescribe single-dose nutrients as drugs for specific conditions, there's growing scientific consensus from large-scale intervention trials that single antioxidant prescriptions (e.g., beta carotene and recently alpha tocopherol) sometimes don't live up to their potential, and antioxidants prescribed in a network (such as food) work better. And, of course, you want to start with an adequate intake and variety of plant foods (fruits and vegetables) in the diet.

OM: Do you educate patients on the possible risks/benefits of nutritional supplements taken to improve/maintain general health and eye health?

DR. RICHER: I explain that the risk of an overdose from a well-formulated multivitamin/multimineral formulation is statistically rare, especially compared to the use of pharmaceutical agents, which, when used inappropriately, represent the third leading cause of death in the United States. I also explain that the problem of vitamin deficiency, coupled with manufactured preservative-rich food and environmental toxins, is epidemic compared to the overuse of multivitamins.

Read about the possible ill effects of herbal remedies and nutritional supplements in OM's interview with Frederick T. Fraunfelder, M.D., professor of the Department of Ophthalmology at the Oregon Health and Science University's Casey Eye Institute. Visit to view this article.

OM: Do you think it's important to educate patients about the option of taking nutritional supplements and vitamins?

DR. RICHER: It's irresponsible not to educate patients on how they can maintain their eye health and visual integrity. If you're examining a pregnant patient, for example, and you don't mention the importance of appropriate cold water fish consumption to IQ, visual acuity and psychiatric (brain) development of the newborn, are you really fulfilling your role as a primary care provider?

If we fail to mention that spinach, blueberries and cold water fish each independently maintain eye health and prevent Alzheimer's disease, haven't we failed to relay important scientific information to our elderly patients?

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 that optometrists, ophthalmologists, other physicians and scientists have attended.

OM: What are the most common/popular nutritional supplements that patients take for general health and for eye health?

DR. RICHER: Depending on studies from medical and scientific journals, some 40% to 60% of Americans take vitamins -- mostly multivitamins and specific nutrients such as vitamins E, C, calcium and folic acid. Optometrists could play an important educational role by educating themselves and their patients about inclusion of supplements within the framework of a healthy lifestyle that includes exercise.

Whether or not you seek to prescribe lifestyle changes and/or nutritional supplements, seek out like-minded, knowledgeable physicians who use comprehensive, preventative medicine in their practices, to expand what we offer our patients.

References available on request

In 1996, Dr. Richer earned his Ph.D. in human physiology and biophysics from Chicago Medical School following 15 years of practice. He's an associate professor of Family and Preventative Medicine at Chicago Medical School and Clinical Optometry at ICO and UMSL.


Optometric Management, Issue: December 2004