While the market for nutritional supplements designed to help manage posterior pole disease grows, many clinicians initially recommend specific foods to address vitamin-deficient diets.
Stuart P. Richer
“From a preventive standpoint, there is thought to be about a 4-mg deficit of lutein in the U.S. diet,” Stuart P. Richer, OD, PhD, FAAO, chief of optometry at the Department of Veterans Affairs North Chicago said. “Therefore, the general maintenance dose should be about 6 mg of lutein in the diet.”
Dr. Richer told Primary Care Optometry News that eating spinach can easily compensate for a lutein deficit. “A cup of spinach every other day will supply at least 10 mg of nonesterified lutein,” he said. “But you want the spinach to be both fresh and cooked — about half fresh and half cooked – because you want to retain the water-soluble vitamins in the spinach, which are valuable, such as folic acid and ascorbic acid. So you don’t want all your spinach cooked.”
The spinach should also be eaten with a meal, with fat, to increase bioavailability, he said.
Dr. Richer asks three questions of his patients who are at risk for age-related macular degeneration: How much dark green leafy vegetables are in your diet? How much oily fish is in your diet? How colorful is your diet in terms of fruits and vegetables? “I believe every optometrist should ask his or her patients these three questions,” Dr. Richer said.
Baby boomer advice
For the 55-year-old baby boomer who has no AMD (or drusen), but who has an 80-year-old parent with AMD, the same questions apply, according to Dr. Richer. “I want to know how much lutein is in the diet and I want to know how much essential fatty acids are in the diet,” he said.
The 80-year-old patient with mild-moderate dry AMD should consume oily fish three times a week, he added. “This includes salmon, tuna, sardines or herring, or 1,000 mg of fish oil per day,” Dr. Richer said.
A can of sardines, for instance, “is ideal three times a week because it is low in polychlorinated biphenyls (PCBs), low in mercury, inexpensive, easily accessible and storable.”
It also contains vitamin D, which, theoretically, works against the formation of new blood vessels, he said.
Dr. Richer also said that 80% of his male patients improve their night vision by increasing dietary lutein and dietary omega-3. “It is amazing how many people are deficient in those two categories,” he said.
These recommendations also enhance light-to-dark adaptation and low-contrast vision.
Dr. Richer said the optometric profession has yet to begin to measure changes in macular degeneration the way the profession measures changes in glaucoma. “This is sad, because glaucoma is less likely to result in catastrophic loss of vision, but macular degeneration does,” he said. “We should be using existing low-tech, low-cost technology to assess visual function in patients with macular degeneration. It is also sad that we are not making even simple dietary recommendations in our practices or following through with supplements when patients fail to heed our advice.”
Diet vs. supplement
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Bruce E. Onofrey
Bruce E. Onofrey, OD, RPh, FAAO, FOGS, director of primary eye care services at Lovelace Medical Center in Albuquerque, N.M., and a PCON Editorial Board member, said vitamins and supplements are way down the list for the 55-year-old baby boomer without AMD but with an aged parent with AMD. Factors such as age, smoking, cholesterol level, blood pressure, weight and exercise all take priority.
“My emphasis is on lifestyle and nutrition, that is, nutrients via diet (dietary carotenoids via fruits and vegetables) and a healthy lifestyle,” Dr. Onofrey said in an interview.
“If we recommend a supplement, it is simply a standard Centrum Silver (Wyeth, Madison, N.J.) multivitamin type supplement,” he continued. “However, many of the studies suggest that it is not a supplement that has a benefit, it is the diet: reducing the fats (red meats) and increasing green leafy vegetables and fruits.” Green leafy vegetables include kale, collard greens and spinach.
“Dietary supplementation is better than taking a synthetic supplement,” he added.
Dr. Onofrey said he would recommend at least one element of the Age-Related Eye Disease Study (AREDS) formulation for the 80-year-old patient with mild-moderate dry AMD. “However, if someone smokes, he or she cannot take the formulation because there is a 30% increase in the risk of lung cancer in smokers who take beta-carotenes,” he said. “I also do not recommend lutein supplementation in this group.”
Moreover, the risk of lung cancer increases in ex-smokers who take the formulation.
Dr. Onofrey said vitamins and supplements may improve night vision symptoms in patients with AMD. “There is a clear benefit to moderate to advanced AMD patients in visual performance if they use supplementation,” he said.
Dr. Richer cited some specific study results that support the use of supplementation. “Symptomatic AMD patients who are not compliant with nutritional intervention should be provided supplementation based on the results of the Lutein Antioxidant Supplementation Trial (LAST), a prospective, double-masked, randomized, placebo-controlled study that controlled for refractive error, cataract and pre-existing eye disease,” he said.
The results of the LAST study have been independently confirmed by Sartore and colleagues and Stringham and colleagues, Dr. Richer said. It was shown that macular pigment (MP), related to lutein intake, is strongly related to improved disability glare, but photostress recovery time after exposure to xenon-white light was also significantly shorter for subjects with higher MP levels, confirming results from LAST, he said.
Dr. Richer added that the LAST II results, scheduled to be published in the May 2007 issue of Optometry, showed that those patients with the lowest intake of lutein benefit the most.
“There are simply not enough lutein and other nutrients in pabulum Centrum or Centrum Silver type A-Z multivitamins to have a physiological or clinical effect,” Dr. Richer said. “This is no small issue, as prolonged photostress recovery, as well as impaired contrast sensitivity function (also helped by lutein), are related to accidental driving death, as reported at the 30th World Congress of Ophthalmology.
Dr. Onofrey said the best “cocktail” of vitamins and supplements for the management of dry AMD at this point in time is the Bausch & Lomb PreserVision formula, which contains beta-carotene, zinc, copper, selenium and vitamins C and E. “This is the only formula that has had any scientific scrutiny to show efficacy,” he said.
Dr. Onofrey noted that the AREDS from a few years ago showed that such a concoction provided about a 20% to 25% reduction in progression of levels 3 and 4 AMD. A new formulation replaces beta-carotene with lutein, he added.
The formula is based on the cascade theory, whereby “anything that has a benefit in increasing macular pigment thickness is good, whereas anything that thins the yellow macular pigment layer that blocks off ultraviolet light is bad,” Dr. Onofrey said in an interview.
For example, smoking has a direct relationship in thinning the macular pigment layer.
The cascade theory also promotes the idea that there are pre-existing enzyme systems that reduce oxidative damage in the eye. “Those enzyme systems are believed to be assisted in their work by metallic cofactors, which are selenium and zinc,” Dr. Onofrey said.
The copper offsets the anemic effect of zinc. “Beta-carotene and vitamin E are believed to be exogenous antioxidant compounds,” he added.
Fortifeye Macular Defense from Fortifeye Vitamins Inc. (Tampa, Fla.) is designed for macular degeneration patients who do not smoke. The product consists of 20 mg of lutein/zeaxanthin, along with slightly lower levels of the AREDS formulation.
“We have also added some nutrients that not only have anti-oxidant activity but new science suggests that may promote anti-angiogenic activity as well,” Michael P. Lange, OD, chairman of the board at Fortifeye Vitamins, told Primary Care Optometry News. Some of the nutrients found in Fortifeye Macular Defense include soy isoflavones, curcumin, green tea, resveratrol, spinach, kale and blueberries.
“The reason that marketing has come a long way over the years in promoting nutritional supplements for the eye is because there is valid clinical evidence that has proved without a shadow of a doubt that the proper nutrients – via foods, whole foods and nutraceuticals – can indeed help certain age-related disease in the retina,” said Dr. Lange, who owns six eye care practices in Florida. “Our products are all natural, with no dyes, and readily assimilate into the blood stream.”
However, Dr. Lange believes that the AREDS formulation “is a fairly archaic vitamin formula that was conceived years and years ago.” For instance, the synthetic form of vitamin E “may cause heart problems,” he said. “New evidence now suggests that using the natural form of vitamin E in supplements will be far superior. We also now know that zeaxanthin combined with lutein may be beneficial.”
Omega-3, especially from microdistilled or molecularly distilled fish oils, “has also been shown to be helpful for the retina, as well as for the heart,” Dr. Lange said. “In fact, fish oil may be a better source for omega-3 because so much fish is contaminated these days. I believe it is a combination of right foods, right supplements, right lifestyle and exercise that works synergistically together at promoting ocular health.”
For more information:
- Stuart P. Richer, OD, PhD, FAAO, is chief of optometry at Department of Veterans Affairs North Chicago and associate professor of Family & Preventive Medicine at Rosiland Franklin University of Medicine and Science/Chicago Medical School. He can be reached at 3001 Green Bay Rd., North Chicago, IL 60064-3095; (224) 610-5440; fax: (224) 610-2924; e-mail: firstname.lastname@example.org. Dr. Richer is also an associate professor of optometry at University of Missouri-St. Louis and Illinois College of Optometry. Dr. Richer is a paid consultant for Bausch & Lomb.
- Bruce E. Onofrey, OD, RPh, FAAO, FOGS, is director of primary eye care services, Lovelace Medical Center, Albuquerque, N.M., and a member of the Primary Care Optometry News Editorial Board. He can be reached at Lovelace at Journal Center, 5150 Journal Center Blvd. NE, Albuquerque, NM 87109; (505) 262-7000, ext. 28328; fax: (505) 262-3366; e-mail: email@example.com.
- Michael P. Lange, OD, is chairman of the board of Fortifeye Vitamins Inc., and in practice at Lange Eye Care and Associates and Lange Eye Institute. He can be reached at 3101 SW College Rd., Ste. 200, Ocala, FL 34474; (800) 660-4393; e-mail: firstname.lastname@example.org or email@example.com; Web sites: www.langeeyecare.com and www.fortifeye.com.
- Richer SP, Stiles W, Statkute L, et al. A placebo-controlled, double-blind, randomized trial of lutein and antioxidant supplementation for the treatment of age-related macular degeneration: The Lutein Antioxidant Supplementation Trial. Optometry. 2004;75:216-30.
- Sartore M, Fregona I, Piermarocchi S, CARMIS Research Group. Effects of short-term supplementation with carotenoids and antioxidants on visual acuity and visual function in age-related macular degeneration. Paper presented at: Association for Research in Vision and Ophthalmology; May 1, 2006; Fort Lauderdale, FL.
- Stringham JM, Hammond Jr, BR, Engles J. The glare hypothesis of macular pigment function. Paper presented at: Association for Research in Vision and Ophthalmology; May 7, 2007; Fort Lauderdale, FL.
- Vision Requirements for Driving Symposium, 30th World Congress of Ophthalmology; February 2006; Sao Paulo, Brazil.