Nutrition for Vision - Energeyes Association

Advisory Board
Consultancies
◦ TearLab
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Biosyntrx, Inc.
Bausch + Lomb
Vistakon
OmniActive Health Technologies
Jeffrey Anshel, OD, FAAO
Ocular Nutrition Society
Corporate Vision Consulting
Editorial Advisory Board
◦ Past-President, Founding Director
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Integrative medicine is a healing-oriented medicine
that takes account of the whole person, including all
aspects of lifestyle.
Optometry Times
Primary Care Optometry News
Optometric Office
Review of Optometry
It emphasizes the therapeutic relationship and makes
use of both appropriate conventional and alternative
therapies.
Life expectancy increased, but quality of life is proving
to be dismal.
1.9 million people are living into their 90’s. This
number has tripled in the past 20 years.
A philosophy that neither rejects conventional
medicine nor accepts alternative therapies uncritically
By 2050, there will be 9 million people living this long.
We have a long “life span” but a shorter “health span”.
We die too slowly from chronic processes like stroke,
heart disease, cancer, diabetes, Alzheimer’s and
Parkinson’s.
Use of natural, effective, less-invasive interventions
whenever possible
Integrative Optometry follows these same principles.
Age-adjusted Incidence Rate
1000
800
600
Females
Males
400
200
Blindness:1 million over age 40
Visual impairment: 2.4 million
Dry Eyes: 12+ million
Macular Degeneration: 10.6 million
Cataracts: 20.5 million
Diabetic Retinopathy: 5.3 million
Glaucoma: 2.2 million (2 million undiagnosed)
These numbers will double in 20 years!
ALL ARE LINKED TO NUTRITIONAL DEFICIENCIES
0
1973
1999
1
Total financial burden of major adult visual
disorders is $51.4 billion
$6.8 billion for cataracts
$5.5 billion for refractive error
$2.9 billion for glaucoma
$575 million for AMD
$493 million for diabetic retinopathy
Prevention is less expensive!
Macular Degeneration
Dry Eye Syndrome
Cataract
Glaucoma
Diabetes/Diet
Age
Gender
Hyperopia
Genetic predisposition
Smoking*
Blue light exposure*
Nutrition*
Obesity*
Cardiovascular Disease*
Hyperlipidemia*
Hypertension*
A condition in which the cells of the macula lutea
degenerate, resulting in blurred vision and
ultimately blindness
YOUR
Management
Co-Management
2
Sponsored the National Eye Institute (NEI)
Started in 1988
The trial included 3,780 participants who had at
least early AMD
Formulation:
Beta Carotene- 15 mg (25,000 IU)
Vitamin C- 500 mg
Vitamin E- 400 IU
Zinc (oxide)- 80 mg
Copper (oxide)- 2 mg
Note: 70% of participants also took full spectrum multiple
vitamin (Centrum) along with the study formula.
For those who initially had early AMD (Category
II), did NOT slow the disease's progression to
intermediate AMD.
Can people with early stage AMD take the AREDS formulation to help
prevent the disease from progressing to the intermediate stage?
There is no apparent need for those diagnosed with early stage AMD to
take the AREDS formulation. The study did not find that the formulation
provided a benefit to those with early stage AMD. If you have early stage
AMD, a comprehensive dilated eye exam every year can help determine if
the disease is progressing. If early stage AMD progresses to the
intermediate stage, discuss taking the formulation with your doctor.
National Eye Institute
Recommendation on Macular Degeneration
“Reduces the risk of advanced AMD”
The effect was in 25% of the study population with
stage III AMD.
Slowed progression from stage III to IV.
Did not prevent AMD.
Did not reverse AMD.
Did not halt progression of AMD.
3
Started in 2007
The population will involve at-risk patients as well as
patients with advanced AMD
1 gm EPA/DHA from Salmon Oil
Both lutein (10mg) and zeaxanthin (2mg)
10 mg lutein, plus 2 mg zeaxanthin, plus 1 gm
EPA/DHA
The original AREDs formula
◦ No beta-carotene
◦ Less zinc
A placebo????
American Society of Retinal Specialists; Preference and
Trends Survey, 2009
AREDS 1
Younger- avg. age 69
All AMD stages
Typical SAD diet
AREDS 2
Older- avg. age 74
Sicker- stage ¾
“Well-nourished”
Diabetes- 7%
67% taking Centrum Silver
(no lutein)
Demographic- unclear
Diabetes- 13%
89% taking Centrum Silver
(with lutein)
Few Hispanics (2%)
Probabilities of progression to advanced AMD:
Placebo: 31%
L/Z: 29%
EPA/DHA: 31%
L/Z+EPA/DHA: 30%
“Addition of lutein + zeaxanthin, DHA+EPA or both to the AREDS
formulation in primary analyses did not further reduce risk of
progression to advanced AMD. However, because of potential
increased incidence of lung cancer in former smokers, lutein +
zeaxanthin could be an appropriate substitute in the AREDS
formulation.”
Placebo
Original
AREDS
formula
Lutein/Zeaxanthin
Lutein- 10mg
Zeaxanthin- 2mg
Formulations Vitamin C
Vitamin E
EPA/DHA
L/Z and
EPA/DHA
EPA- 650mg
DHA- 350mg
AREDS plus
L/Z and
EPA/DHA
Beta-carotene Zinc Oxide
Cupric
Oxide
1 (Original)
500 mg
400 IU
15 mg (25,000 IU)
80 mg
2 mg
2
500 mg
400 IU
0 mg
80 mg
2 mg
3
500 mg
400 IU
0 mg
25 mg
2 mg
4
500 mg
400 IU
15 mg (25,000 IU)
25 mg
2 mg
Formulation:
Beta Carotene- 15 mg (25,000 IU)
Vitamin C- 500 mg
Vitamin E- 400 IU
Zinc (oxide)- 80 mg ?
Copper (oxide)- 2 mg
Lutein/Zeaxanthin- 10mg/2mg
AREDS2
4
Lutein Antioxidant Supplement Trial
“The main study objective is to determine if these
nutrients will decrease a person’s risk of
progression to advanced AMD, which often leads
to vision loss.”
Still does NOT address prevention, halting or
reversal!
12 month study; 90 male patients at VA hospital
Formulae: Group A: 10 mg of lutein
Group B: 10 mg lutein w/multiple vitamin
w/antioxidants
Group C: placebo
Results: Lutein alone and lutein with antioxidants
showed a 50% increase in average macular pigment
ocular density. Both groups significantly improved
some measures of visual function, including glare
recovery, contrast sensitivity and visual acuity.
5,205 women without AMD, average age 63
All were permitted to take multivitamins with B-6, B-12 and folate up
to, but not exceeding, recommended daily allowance (RDAs).
“Vitamin D Status and Early Age-Related
Macular Degeneration in Postmenopausal
Women”
Those getting the B-6, B-12 and folate supplements received much
larger amounts: 2.5 mg of folate (folic acid), 50 mg of vitamin B6
(pyridoxine) and 1 mg of B12.
Conclusion: High serum 25(OH)D concentrations
may protect against early AMD in women younger
than 75 years.
After an average of 7.3 years of treatment and follow-up, there were
55 cases of AMD in the combination treatment group and 82 in the
placebo group (relative risk, 0.66; 95% confidence interval, 0.470.93 [P = .02]). For visually significant AMD, there were 26 cases in
the combination treatment group and 44 in the placebo group
(relative risk, 0.59; 95% confidence interval, 0.36-0.95 [P =.03])
Amy E. Millen, PhD, et al
Arch Ophthalmol. 2011;129(4):481-489
Folic Acid, Pyridoxine, and Cyanocobalamin Combination Treatment and Age-Related Macular
Degeneration in women.
Christen W, Glynn R, Chew E, et al.
Archives of Internal Medicine. Vol 169 (4): Feb 23, 2009
Yellow, orange, red lipophilic pigments
~ 600 known carotenoids
40-50 in typical human diet
14 found in serum
Beta carotene is an effective antioxidant
It is not an appropriate source of Vitamin A
◦ Does not as readily covert to pre-formed Vitamin A (retinol) in the
older population as it does in younger people
◦ Does not convert to vitamin A if there are sufficient stores of Vitamin
A in the system.
◦ Lutein
Lutein, β-Carotene, Lycopene,
α-Carotene, Zeaxanthin,
Zeaxanthin β-Cryptoxanthin
Increased risk of cancer in smokers and SECOND-HAND
smokers!
Interferes with the absorption of lutein and zeaxanthin
© Kemin Industries, Inc. 2006 All rights reserved. ® ™ Trademarks of Kemin Industries, Inc., U.S.A.
5
“Higher beta-carotene intake was
associated with an increased
risk of AMD.”
Dietary Antioxidants and the Long-term Incidence
of Age-Related Macular Degeneration
(The Blue Mountain Eye Study)
Jennifer, SL Tan, et al. Ophthalmology 2008; 115:334-341
Note
for patients with BMI over 30:
Lutein is sequestered in adipose tissue
and therefore is less available to ocular
tissue.
It is not beyond our scope to discuss
weight issues with our patients.
Food Item
mg lutein & Zeaxanthin per
100g
Kale, raw
39.5
Spinach,
Spinach,raw
raw
12.2
12.2
Collard greens, boiled
7.7
Romaine lettuce, raw
2.3
Zucchini, raw
2.1
Broccoli, raw
1.7
Corn, boiled
1.0
Green beans, boiled
0.7
Baby carrots, raw
0.4
Cabbage, boiled
Whole
rawraw
Wholeeggs,
eggs,
0.3
0.3
0.3
Oranges, raw
0.1
Tomatoes, raw
0.1
“Cage-Free” Chickens
6
CageCage-Free: This label simply means the absence of a cage. It doesn’t mean
the absence of fences or enclosures in general. Birds that qualify as cagefree can still be packed tightly into an overpopulated and darkened barn.
FreeFree-Range: Required to have access to the outdoors—but that may amount
to a narrow patch of dirt. Access to it can be a tiny door cut into the back of
the shed, which in an overcrowded barn stuffed with hens, the birds may not
ever notice, let alone use.
Organic: Birds are antibiotic and hormone-free, in addition to being provided
with access to the outdoors. Still, some organic farms abuse the system by
housing their hens in overcrowded sheds—with a small, unused door.
Certified Humane: According the Humane Society, even this certification
allows for farmers to house chickens indoors at all times if they choose, and
also permits beak cutting. A similar term, "American Humane Certified"
allows laying hens to be caged.
What to Look for Instead
PasturePasture-raised is a label used increasingly by smaller, sustainable chicken
farms to indicate that they legitimately raise their birds outside, on an actual
pasture. Hens also enjoy access to shelter when they choose to take it, and
they’re raised without the use of harmful chemicals or painful procedures.
Not a naturally occurring nutrient in
traditional diets
Is generated from the metabolism of
lutein
Does not convert from zeaxanthin
Meso-zeaxanthin
Zeaxanthin
Lutein
“In the US the presence of MZ in the macula is
not likely due to dietary sources, although this a
possibility when consuming eggs of chickens fed
MZ”
Lutein, zeaxanthin, meso-zeaxanthin content in egg yolk
and their absence in fish and seafood.
HM Rasmussen, T Muzhingi, EMR Eggert, EJ Johnson
J. Food Compos. Anal. (2012),
dx.doi.org/10.1016/j.jfca.2012.04.009
MPOD increase with supplementation
Four hundred (400) patients, with a minimum of six (6) months between
tests of MPOD, were selected.
• The average initial MPOD of the 400 patients analyzed was .23
• The average follow-up MPOD of the 400 patients analyzed was .37
• The average percent increase in MPOD of the 400 patients was 62%
Of all patients (>2,000) reviewed, approximately 21% were
measured at or below .25 MPOD
Lutein supplementation of 12 mg/d slowed loss of
mid-peripheral visual field on average among
nonsmoking adults with retinitis pigmentosa taking
vitamin A.
Clinical Trial of Lutein in Patients With Retinitis Pigmentosa Receiving Vitamin A
Eliot L. Berson, MD, et al
Arch Ophthalmol. 2010;128(4):403-411
• 85% of all patients demonstrated an increase in MPOD
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The second most abundant mineral in the body (calcium).
Critical in most metabolic processes, including DNA
replication.
Zinc oxide is the type that was used in the AREDS
studies, and the type which is still used by most of the
formulators.
Monomethionine zinc is the most bioavailable form of zinc
and the only form that does not interfere with copper
absorption.
80 mg of zinc oxide is too much for long term daily
consumption.
High concentrations of zinc have been found in subretinal pigment epithelial deposits, and have been
associated with urinary tract disorders.
Recommended daily intakes are:
Infants: 5 mg
Children:10 mg
Women:12 mg
Pregnant Women:15 mg
Lactating Women:16 mg
Men:15 mg
The tolerable upper limit for zinc was set at 40
mg per day for adults over 19.
Copper's presence in the food supply is
ubiquitous.
Because copper is a pro-oxidant when free and
unbound, it can quickly generate free radicals.
Copper appears to be one of the main
environmental factors that trigger the onset and
enhance the progression of Alzheimer's disease
by preventing the clearance and accelerating the
accumulation of toxic proteins in the brain.
Vitamin E
A 2005 study in the JAMA suggested that excessive (400
IU) Vitamin E can be deadly!
A closer look shows that the isolated finding applied only
to an older group of patients (over the age of 70), had a
long history of heart disease, stroke or diabetes, and
were also taking a combination of medications, including
ACE inhibitors, calcium channel blockers, anti-platelet
agents and lipid-lowering agents during the course of the
study.
Vitamin E Family
Tocopherol (T)
Tocotrienol (T3)
Delta-T
Gamma-T
A significant percentage were also cigarette smokers!!
Beta-T
©1995-2003 by Michael W. Davidson
Delta-T3
GammaT3
Beta-T3
Alpha-T
AlphaT3
48
8
Are blocked by tocopherols- especially alphatocopherol
Best source- annatto beans: contain gamma and deltatocotrienol (best for cardio-protection, cancer and diabetes)
Super-antioxidant (anti-cataract)
Increases tear production
Reduces diabetic retinopathy
Targets angiogenesis (AMD)
Important in collagen formation, wound healing,
neurotransmitter synthesis, drug detox,
antioxidant, and more.
Deficiency results in bleeding gums, loose teeth,
pinpoint hemorrhages, frequent infections, slow
healing, cataracts(?)
Overdose causes nausea, diarrhea
Also shown to reduce bleeding and bruising
Sodium ascorbate- easier on stomach
One French study in 1942 of improved night vision of
RAF pilots in WWII(??)
Since the structure of anthocyanins is consistent with an
ability to donate hydrogen atoms, it is powerful
antioxidant.
Anthocyanins have been shown to scavenge chemicallygenerated superoxide and nitric oxide radicals, as well
as quench singlet oxygen.
Keeps vitamin C in a reduced state- more effective
Also a blood thinner, so moderation is suggested.
A 24 month Italian double-blind AMD study
showed an improvement of visual functions and
fundus alterations in early AMD.
Phototrop® is a combination of:
◦
◦
◦
◦
DHA: increases cellular permeability
EPA: anti-inflammatory
CoQ10: cleans out the mitochondria (antioxidant)
Acetyl-L Carnitine: drives CoQ10 across the membrane
Omega 3 fatty acid derived from alpha-linolenic
acid
Abundant in the retina
◦ Highest concentration of any cell type in the body.
◦ Concentrated in the rod outer segments
◦ Constitutes 30-40% of total fatty acid in the retina/brain- far
more than any other tissue.
Fundus alterations:
pre treatment
Fundus alterations:
post treatment
Essential role in visual development
◦ “Infants supplemented with DHA containing formula
had significantly greater visual acuity score than
placebo”
Fliesler et al. Prog Lipid Res 1983, 22:79–131;
Connor et al. Nutr Rev 1992, 50:21–29;
Cho et al. Am. J. Clin. Nutr. 2001, 73:209-218;
Birch et al. Ped. Res. 1998, 42: 201-209
9
Oxidative stress is believed to play a
fundamental role in the pathogenesis of AMD
and other retinal degenerations
Patients with late AMD have been shown to
have significantly lower antioxidant enzyme
levels and higher lipid peroxidation by-product
levels compared with patients with early AMD
Oxidative damage is a prominent feature of
nuclear and cortical cataracts
Vitamin E
Xanthophylls- Lutein/Zeaxanthin
Ascorbic Acid (Vitamin C)
Coenzyme Q10
Vitamin A
N-acetyl-cysteine
Proteins: Superoxide Dismutase,
Glutathione Peroxidase
Flavinoids
Carotenoids- Beta carotene,
lycopene
Herbals: Therflavin, Ginko biloba,
etc
Pycnogenol- grape seed extract
Selenium
Zinc
Melatonin
Berries: Blueberries, blackberries, raspberries, strawberries, acai
and cranberries
Beans: Small red beans and kidney, pinto and black beans
Fruits: Many apple varieties (with the peel left on), avocados,
cherries, green and red pears, fresh or dried plums, pineapple,
oranges and kiwi fruits
Vegetables: Artichokes, spinach, red cabbage, red and white
potatoes (with peel), sweet potatoes and broccoli
Beverages: Green tea, coffee, red wine and some fruit juices
Nuts: Walnuts, pistachios, pecans, hazelnuts and almonds
Grains: Whole grain-based products
Dessert: Dark chocolate
A phytoalexin produced naturally by several plants when
under attack by bacteria or fungi.
Phytoalexins are antibacterial and anti-fungal chemicals
produced by plants as a defense against infection by
pathogens.
Resveratrol has also been produced by chemical
synthesis, and is sold as a nutritional supplement.
Anti-cancer, antiviral, neuroprotective, anti-aging, antiinflammatory and life-prolonging effects have been
reported.
Requires about 25-50 glasses of wine PER DAY!
10
One-year consumption of a grape nutraceutical
containing resveratrol improves the
inflammatory and fibrinolytic status of patients
in primary prevention of cardiovascular disease
The American Journal of Cardiology, 07/30/2012
Sponsored by Welch’s Grape Juice
“It's important to understand that most of the scientific
research on the cacao bean refers to organic cacao in its
raw,raw,
unprocessed,
unprocessed,
and
and
unadulterated
unadulterated form. Note that
when the cacao beans are processed by roasting or
heating, there will be a loss of some of the nutrient value.”
Dr. Charles Suber
"Most chocolate, in fact, isn't flavanol-rich, but all
chocolate is rich in fat and calories.“
Norm Hollenberg, a radiology professor and
flavanol expert at Harvard Medical School
Positives
Negatives
Food
Caffeine Content
All-cause mortality
Addiction
Coffee
50-120mg
Alzheimer’s
Cancer
Decaf
1-5mg
Gall stones
GI problems
Tea- Black
45mg
Parkinson’s
Sleep disorders
Tea- Green
20mg
Cognitive performance
Psychological effects
Tea- White
15mg
Anti-diabetic
Cholesterol
Coke
34mg
Liver protection
Blood pressure
Cancer
Pregnancy
Cardio-protective
Iron deficiency
Laxative
Coronary artery disease
Gout
Acne
Antioxidants
GLAUCOMA
Pepsi
38mg
Dark Chocolate
20mg
Milk Chocolate
6mg
11
2 tablets Excedrin: 130 mg
Vital Energy water: 150 mg
5-Hour Energy: 125mg
Red Bull (250 ml): 80 mg
16-ounce Snapple ice tea: 42 mg
1 cup Ben & Jerry’s No Fat Fudge Frozen Yogurt:
85 mg
1 cup Dannon Coffee Yogurt: 45 mg
Barq’s Root Beer: 22 mg
Lycium barbarum (Chinese)
High in polysaccharides
33 minerals; 18 amino acids
6 essential vitamins
High in zeaxanthin, lutein, etc.
Highest source of zeaxanthin
High antioxidant properties
Oxygen Radical Absorbance Capacity
Dry Eye Syndrome (DES) is a disorder of the
tear film due to either diminished tear production
or excessive tear evaporation.
Mild
Moderate
Severe
12
Tear Film
Destabilization
(Loss of Protection)
Desiccation of
Ocular Surfaces
Inflammation
Cytokines
Injurious Agents
•Free Radicals
•Toxins
•Microbes
•Allergens
Environment
Age/Gender
LASIK
Lid Abnormality
Computer Vision Syndrome
Systemic Medications
Chronic Diseases
Contact Lens
•Ocular Surfaces
•Epithelium
•Lacrimal Gland
Artificial Tears
Punctal Plugs
Lipid Layer Enhancement
Tear Quality Enhancement
Epithelial Surface Treatment
-76% of patients rated their conditions as the
same or worse compared with the previous year
despite treatment. (Kozma, 2000)
Orals
Anti-Inflammatory
Block
the inflammatory pathway in the immune system
Steroids (Alrex / Lotemax / Vexol) - contain cytokine
inhibitors
Cyclosporine A- Restasis (Allergan)- immunosuppressant
Essential Fatty Acids (EFA) – natural source
Anti-evaporatives
Secretagogues
Mucomimetics
Hormones
Anti-inflammatory
Polymers
Autologous serum
Homeopathics
Orals
Essential Fatty Acids
Hydro-Eye
Hydrate Essential
TheraTears Nutrition
BioTears
EyePromise EZ Tears
13
Omega-3
Omega-3
OmegaOmega-3
Prospective, Randomized, Double-Masked, Placebo-controlled Clinical Trial of an
1. Pilot,
Omega-3 Supplement for Dry Eye. Wojtowicz, JC et al. Cornea. 30(3):308-314, March 2011.
Omega-3
2. Short Term Consumption of oral Omega-3 and Dry Eye Syndrome.
Kangari H, Eftekhari MH, Sardari S, Hashemi H, Salamzadeh J, GhassemiBroumand M, Khabazkhoob M. Ophthalmology. 2013 May 1. pii: S01616420(13)00337-0. doi: 10.1016/j.ophtha.2013.04.006
Omega-3
3. A randomized controlled trial of omega-3 fatty acids in dry eye syndrome.
Omega-3
Bhargava R, Kumar P, Kumar M, Mehra N, Mishra A. Int J Ophthalmol.
2013;6(6):811–6
4.
Omega-3
5.
PGE1
Reduce inflammation and inhibit blood clotting.
Capable of reducing pain, swelling and redness
associated with inflammation, particularly in
mucosal tissues, which includes the eyes.
Can only be produced by Omega-6 fatty acids
PGE2
Are opposite of PGE1s but can only be produced by
Omega-6 fatty acids, as well.
PGE3
Are available from Omega-3 fatty acids
The Omega-3 fatty acid, EPA, also plays an
important anti-inflammatory role.
It appropriately blocks the release of Omega-6
arachidonic acid, so without sufficient Omega-3s
in the diet, chronic inflammation becomes one of
the problems now linked to many degenerative
diseases of the eye.
Are pro-inflammatory mediators that constrict blood vessels,
increase body temperature, and encourage blood clotting.
These events are lifesaving when the body suffers a wound
or injury, for without PGE2s, a person could bleed to death.
However, in excess, this type of prostaglandin is harmful
because it sets up a chronic inflammatory condition in the
body.
14
Provide overall anti-inflammatory effect
Increase fluidity of meibomian gland secretions
Improve tear film quality and decrease evaporative
loss
Optimize function of goblet cells
Is dry eye an indicator of
systemic essential fatty
acid deficiency or
imbalance ?
Improve epithelial cells microvilli expression and
adhesion
Ginkgo biloba
Omega-3
Fish Oil
Bilberry
Flaxseed oil
Vitamin E
Resveratrol
CASE REPORT
◦ Omega-3 fatty acids may lower thromboxane A(2) supplies within
the platelet as well as decrease factor VII levels. This case report
illustrates that fish oil can provide additive anticoagulant effects
when given with Warfarin.
STUDY
◦ Effects of Marine Fish Oils on the Anticoagulation Status of
Patients Receiving Chronic Warfarin Therapy….. “Fish oil
supplementation in doses of 3-6 grams per day does not seem to
create a statistically significant effect on the anticoagulation status
of patients receiving chronic Warfarin therapy”.
Ann Pharmacother. 2004 Jan;38(1):50-2.
J Thromb Thrombolysis. 1998 Jul;5(3):257-261.
Blood Thinners
Oil
Omega-3
Omega-6
GammaLinolenic
Acid (GLA)
FLAX
85%
15%
NONE
EPO
NONE
75%
9%
Borage
75%
NONE
23%
Black
Currant Seed Oil
15%
65%
18%
Does contain a large amount of Omega-3 EFA
Highly unstable, must be refrigerated
Contains NONE of the nutrient co-factors
necessary to ensure conversion to PGE1 antiinflammatory
Does not enhance production of lactoferrin
Excess now linked to cortical opacities and
prostate cancer.
May cause intestinal blockage, thyroid problems
and reduces platelet aggregation.
15
“Flaxseed oil may be an effective antiinflammatory nutritional therapy alternative to
long-term antibiotics”
“Omega-6 administration increases the
PGE1 levels in tears of patients with
Sjögren’s Syndrome and improves
ocular surface signs and symptoms of
ocular discomfort.”
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”
Systemic Omega-6 EFA Treatment and PGE1 Tear Content in
Sjögren’s Syndrome Patients.
Aragona, P., Bucolo,C., et al
IOVS 2005; 46:4474-4479
Do not confuse all the processed food items that contain
hydrogenated trans-fats with Omega 6 essential fatty
acid intake. All fatty acids are destroyed by the
hydrogenation process.
The series one anti-inflammatory prostaglandins
(PGE1s) from natural Omega 6s are more specific to
mucosal tissues (eyes) than the series three
prostaglandins (PGE3s) from Omega 3s.
“Here are a few samples- see which one
you like the best”.
“Just go to the drug store and pick up
some artificial tears”……..
16
The aqueous humor, which feeds the lens, has the
highest amount of Vitamin C of any fluid in the
body (26x more than in serum).
The lens has the highest concentration of protein
of any organ.
Recent studies have found significant amounts of
lutein and zeaxanthin in the lens.
Carbohydrate intake
Water Content
Protein
Sodium
Potassium
Calcium
Glutathione
Higher ALA (omega-3 alpha-linolenic acid)
intake is associated with a greater age-related
change in lens nuclear density.
BMI
◦ BMI > 30 or waist size > 35" is associated with two fold
increase in prevalence of PSC opacities
◦ Diabetes increases the odds for PSC opacities 4-fold.
Decrease
Ascorbic Acid
◦ Is related to increased odds for cortical opacities
Increase
Lu M, Taylor A. Chylack LT, Rogers G, et al. J Am Coll Nutr 2007 Apr;26(2):133-40
Alcohol
◦ Consumption of hard alcohol is associated with increased
risk for nuclear and cortical opacities.
◦ In contrast, moderate wine drinking decreases the risk for
cortical opacities.
(Flax seed oil is 85% ALA)
Age-related cataract is associated with
type 2 diabetes and statin use
1991
In this population, statin use was substantially higher in
patients with type 2 diabetes and was associated with agerelated cataracts.
Machan CM, Hrynchak P, Irving EL.
Optom Vis Sci. 2012 Aug;89(8):1165-71K
Vitamin E protects the lens against UVB-induced
cataract. (Leske, MC, et al. Ophthalmology 1998;105:831-6)
Canadian study found 200mg C, 400 IU E
protective for cataracts.(McRoberston J, et al. Am J Clin Nutr,
Antioxidant vitamins linked to a reduced risk of
cataract by 1/3 (Leske, MD, et al. Ophthal. 1998)
Vitamin E reduced cataract by half (Leske, MD, et al.
Ophthal. 1998)
17,000 physicians found daily multivitamin
reduced cataracts by 25% (Schaumberg D, et al. Am J Clin
Nutrition 2000;72:1417-8)
17
Network Antioxidants
•Lipoic Acid
•COQ10
Network Antioxidants greatly
enhance the power of one another.
They are particularly effective in
slowing down the aging process and
boosting the body’s ability to fight
disease.
•Glutathione
•Vitamin E
Precursor to glutathione- an amino acid
complex
Glutathione is the “master” antioxidant
Glutathione is destroyed by digestive process,
therefore must be created internally.
Glutathione is depleted in cataractous lenses
•Vitamin C
“…turmeric and curcumin are effective against the
development of diabetic cataract in rats.
Further, these results imply that ingredients in the
study’s dietary sources, such as turmeric, may be
explored for anti-cataractogenic agents that
prevent or delay the development of cataract.”
The presence of oxidative stress in selenite cataract
development and its prevention by resveratrol
support the possibility that high natural consumption
of resveratrol in food can help prevent human senile
cataract.
“The effect of resveratrol in experimental cataract model formed by sodium selenite”
Dogeney, S. et al
Curr Eye Res. 2006 Feb;31(2):147-53.
Curcumin and Turmeric Delay Streptozotocin-Induced
Diabetic Cataract in Rats
Invest Ophthalmol Vis Sci. 2005;46:2092–2099)
A powerful dipeptide amino acid is a combination of
histidine and alanine.
N-acetylcarnosine (1%)
Found in high concentrations in skeletal tissues.
Addresses the anti-aging issues of cellular crosslinking, which contributes to cataract formation.
Take with zinc.
Topical anti-cataract eye drop
Antioxidant, anti-glycating and chelating dipeptide,
developed in Russia
Precursor for L-carnosine
Human study: 41% of participants showed
improvement in visual acuity at 6 mos.(76 eyes)
No subjects had worse vision at 24 mos.
18
NACA injections prevented cataract formation in
rats
GSH levels were significantly decreased but the
rats that received NACA injections had these
levels of GSH replenished.
NACA inhibits cataract formation by:
◦ Limiting protein carboxylation
◦ Preventing lipid peroxidation
◦ Replenishing antioxidant enzymes
In vivo inhibition of l-buthionine-(S,R)-sulfoximine-induced cataracts by a
novel antioxidant, N-acetylcysteine amide
The development of AMD and nuclear cataract
are associated with a high dietary glycemic
index.
“…these foods may advance damage to the
metabolically limited tissue of the lens by
exposing this tissue to glucose for longer
periods.”
1. Chiu CJ, Hubbard LD, Armstrong J, et al. Dietary glycemic index and carbohydrate in relation to
early age-related macular degeneration. Am J Clin Nutr 2006 Apr;83(4):880-6.
2. Chiu CJ, Milton RC, Gensler G, Taylor A. Dietary carbohydrate intake and glycemic index in
relation to cortical and nuclear lens opacities in the Age-Related Eye Disease Study. Am J Clin
Nutr 2006 May;83(5):1177-84.
Carey JW, Pinarci EY, Penugonda S, Karacal H, Ercal N.
Free Radic Biol Med. 2011 Mar 15;50(6):722-9
“Dietary omega 3 fatty acids
decrease intraocular pressure
with age by increasing aqueous
outflow”
CONCLUSION: Dietary manipulation may provide a
modifiable factor for IOP regulation.
Cellini M, et al. Fatty acid use in glaucomatous optic neuropathy
treatment. Acta Ophthalmol Scand Suppl . 1998;227:41-42.
“α-Tocopherol deserves attention beyond
its antioxidant properties for protecting
retina from glaucomatous damage”
Clinical evaluation of the neuroprotective effect of alpha-tocopherol against
glaucomatous damage
Eur J Ophthalmol 2007; 17: 528 - 533
A study has found that the combination of a
standardized extract of bilberry and French
maritime pine bark can reduce the risk of
glaucoma.
Molecular Vision 2008; 14:1288-1292
"Effects of Mirtogenol® on ocular blood flow and intraocular hypertension
in asymptomatic subjects"
Robert Steigerwalt Jr, et. al
19
Mirtogenol ® lowered elevated IOP in patients
almost as effectively as latanoprost, however,
it takes much longer (24 vs 4 weeks). The
combination of both was more effective for
lowering IOP and the combination yielded
better retinal blood flow
Mirtogenol® potentiates latanoprost in lowering intraocular pressure and improves ocular blood flow
in asymptomatic subjects
Robert D Steigerwalt Jr, Gianni Belcaro, Paolo Morazzoni, et al
Clinical Ophthalmology, May 2010 , Volume 2010:4
Our results suggested that oral administration of
BCACs may induce a beneficial decrease in IOP
levels in healthy subjects as well as in patients with
glaucoma.
A natural plant extract from the bark of the
maritime pine tree which grows exclusively along
the coast of southwest France in Les Landes de
Gascogne
It’s a powerful antioxidant
Acts as a natural anti-inflammatory
Selectively binds to collagen and elastin
It aids in the production of endothelial nitric oxide
which helps to dilate blood vessels.
Effects of Black Currant Anthocyanins on Intraocular Pressures in Healthy
Volunteers and Patients with Glaucoma
Hiroshi Ohguro, Ikuyo Ohguro, and Saeko Yagi
Journal of Ocular Pharmacology and Therapeutics.
doi:10.1089/jop.2012.0071.
Eat foods rich in carotenes and bioflavonoids, such as dark leafy
greens, yellow and orange vegetables and dark berries.
Avoid stimulating foods (ex. Sugar and refined foods), alcohol,
drugs, smoking, coffee, and salt
Vitamin C (500 mg four times a day)
Vitamin E (400 IU a day), vitamin A (5,000 IU a day), and
thiamine (10 mg a day)
Lipoid Acid (150 mg a day)
Acetyl-L-carnitine (200-500 mg a day)
Taurine (500 mg a day)
Selenium (200 mcg a day) and zinc (30 mg a day)
Omega-3 fatty acids (300 to 500 mg daily)
Ginkgo (120 mg a day) to improve blood circulation
Black Current Seed extract- (50 mg daily)
As compared with clinical risk factors
alone, common genetic variants
associated with the risk of diabetes had a
small effect on the ability to predict the
future development of type 2 diabetes.
N Engl J Med. 2008;359:2208-2219.
20
Age-adjusted Prevelence of Diagnosed Diabetes
Among US Adults
1994
Missing
Missing
data
data
4.5%–5.9%
4.5%–5.9%
7.5%–8.9%
7.5%–8.9%
<4.5%
<4.5%
6.0%–7.4%
6.0%–7.4%
≥9.0%
≥9.0%
Age-adjusted Prevelence of Diagnosed Diabetes
Among US Adults
Age-adjusted Prevelence of Diagnosed Diabetes
Among US Adults
1995
1996
Missing
Missing
data
data
4.5%–5.9%
4.5%–5.9%
7.5%–8.9%
7.5%–8.9%
<4.5%
<4.5%
6.0%–7.4%
6.0%–7.4%
≥9.0%
≥9.0%
Missing
data
Missing
data
4.5%–5.9%
4.5%–5.9%
7.5%–8.9%
7.5%–8.9%
<4.5%
<4.5%
6.0%–7.4%
6.0%–7.4%
≥9.0%
≥9.0%
Age-adjusted Prevelence of Diagnosed Diabetes
Among US Adults
Age-adjusted Prevelence of Diagnosed Diabetes
Among US Adults
1997
1998
Missing
Missing data
data
4.5%–5.9%
4.5%–5.9%
7.5%–8.9%
7.5%–8.9%
<4.5%
<4.5%
6.0%–7.4%
6.0%–7.4%
≥9.0%
≥9.0%
Missing
Missing
data
data
4.5%–5.9%
4.5%–5.9%
7.5%–8.9%
7.5%–8.9%
<4.5%
<4.5%
6.0%–7.4%
6.0%–7.4%
≥9.0%
≥9.0%
21
Age-adjusted Prevelence of Diagnosed Diabetes
Among US Adults
Age-adjusted Prevelence of Diagnosed Diabetes
Among US Adults
1999
2000
Missing
data
Missing
data
4.5%–5.9%
4.5%–5.9%
7.5%–8.9%
7.5%–8.9%
<4.5%
<4.5%
6.0%–7.4%
6.0%–7.4%
≥9.0%
≥9.0%
Missing
Missing data
data
4.5%–5.9%
4.5%–5.9%
7.5%–8.9%
7.5%–8.9%
<4.5%
<4.5%
6.0%–7.4%
6.0%–7.4%
≥9.0%
≥9.0%
Age-adjusted Prevelence of Diagnosed Diabetes
Among US Adults
Age-adjusted Prevelence of Diagnosed Diabetes
Among US Adults
2001
2002
Missing
data
Missing
data
4.5%–5.9%
4.5%–5.9%
7.5%–8.9%
7.5%–8.9%
<4.5%
<4.5%
6.0%–7.4%
6.0%–7.4%
≥9.0%
≥9.0%
Age-adjusted Prevelence of Diagnosed Diabetes
Among US Adults
2003
Missing
data
Missing
data
4.5%–5.9%
4.5%–5.9%
7.5%–8.9%
7.5%–8.9%
Missing
data
Missing
data
4.5%–5.9%
4.5%–5.9%
7.5%–8.9%
7.5%–8.9%
<4.5%
<4.5%
6.0%–7.4%
6.0%–7.4%
≥9.0%
≥9.0%
Age-adjusted Prevelence of Diagnosed Diabetes
Among US Adults
2004
<4.5%
<4.5%
6.0%–7.4%
6.0%–7.4%
≥9.0%
≥9.0%
Missing
data
Missing
data
4.5%–5.9%
4.5%–5.9%
7.5%–8.9%
7.5%–8.9%
<4.5%
<4.5%
6.0%–7.4%
6.0%–7.4%
≥9.0%
≥9.0%
22
Age-adjusted Prevelence of Diagnosed Diabetes
Among US Adults
2005
Missingdata
data
Missing
4.5%–5.9%
4.5%–5.9%
7.5%–8.9%
7.5%–8.9%
2006
<4.5%
<4.5%
6.0%–7.4%
6.0%–7.4%
≥9.0%
≥9.0%
Age-adjusted Prevelence of Diagnosed Diabetes
Among US Adults
2007
Missing
data
Missing
data
4.5%–5.9%
4.5%–5.9%
7.5%–8.9%
7.5%–8.9%
Missingdata
data
Missing
4.5%–5.9%
4.5%–5.9%
7.5%–8.9%
7.5%–8.9%
<4.5%
<4.5%
6.0%–7.4%
6.0%–7.4%
≥9.0%
≥9.0%
Age-adjusted Prevelence of Diagnosed Diabetes
Among US Adults
2008
<4.5%
<4.5%
6.0%–7.4%
6.0%–7.4%
≥9.0%
≥9.0%
Age-adjusted Prevelence of Diagnosed Diabetes
Among US Adults
2009
Missing
Missing
data
data
4.5%–5.9%
4.5%–5.9%
7.5%–8.9%
7.5%–8.9%
Age-adjusted Prevelence of Diagnosed Diabetes
Among US Adults
Missing
data
Missing
data
4.5%–5.9%
4.5%–5.9%
7.5%–8.9%
7.5%–8.9%
<4.5%
<4.5%
6.0%–7.4%
6.0%–7.4%
≥9.0%
≥9.0%
Age-adjusted Prevelence of Diagnosed Diabetes
Among US Adults
2010
<4.5%
<4.5%
6.0%–7.4%
6.0%–7.4%
≥9.0%
≥9.0%
Missing
data
Missing
data
4.5%–5.9%
4.5%–5.9%
7.5%–8.9%
7.5%–8.9%
<4.5%
<4.5%
6.0%–7.4%
6.0%–7.4%
≥9.0%
≥9.0%
23
The Glycemic Index (GI) is a ranking of
carbohydrates on a scale from 0 to 100
according to the extent to which they raise
blood sugar levels after eating.
High GI Foods are those which are rapidly
digested and absorbed and result in marked
fluctuations in blood sugar levels.
Low GI foods, by virtue of their slow digestion
and absorption, produce gradual rises in blood
sugar and insulin levels, and have proven
benefits for health.
smaller rise in blood glucose levels after meals
diets can help people lose weight and can improve
the body's sensitivity to insulin
can improve diabetes control
foods keep you fuller for longer
can prolong physical endurance
high GI foods help re-fuel carbohydrate stores
after exercise
www.glycemicindex.com
“…this shows an association of consuming a diet
rich in DHA with lower progression of early AMD.”
In addition to the AREDS supplement, lower dGI
with higher intakes of DHA and EPA was associated
with reduced progression to advanced AMD.
“Does eating particular diets alter risk of age-related macular degeneration
in users of the age-related eye disease study supplements?”
Chiu CJ,, et al
Br J Ophthalmol. 2009 Jun 12.
Chromium
Magnesium
Calcium
Potassium
Vitamin B3
Antioxidants
In patients with type 2 diabetes, researchers show a
6-month treatment with a low-glycemic index diet
may lower HbA(1c) levels compared with a highcereal fiber diet.
Effect of a Low-Glycemic Index or a High-Cereal Fiber Diet on Type 2 Diabetes
Jenkins, D, et al
JAMA, 2008; 300(23):2742-2753
◦ Vitamin C
◦ Vitamin E
◦ Selenium
Omega-3 PUFA
24
AcetylAcetyl-L-Carnitine
Omega-3 polyunsaturated fatty acid
supplements have been shown to lower
plasma triglyceride levels in persons
with type 2 diabetes.
A
powerful antioxidant that has been
proven to improve brain function, alter
mood, and increase cellular energy when
taken with a balanced amount of Lipoic
Acid.
Increases glucose metabolism
Friedberg CE, et al. Fish oil and glycemic control in diabetes: a metaanalysis. Diabetes Care . 1998;21:494-500..
Lipoic Acid is the nutrient that intracellularly
regenerates most all other nutrients.
Along with acetyl-L-carnitine, it increases
ATP cellular energy
Both fat and water soluble antioxidant
Shown to improve fasting blood glucose,
HbA1c and lipid peroxide status, a marker of
oxidative stress.
Healthy Habit
Body Mass Index >30
Physical Activity 12x per mo.
Smoking
1988-1994
2001-2006
28%
36%
53%
43%
26.9%
26.1%
Fruits/Veggies 5X day
42%
26%
Moderate alcohol use
40%
51%
All 5 healthy habits
15%
8%
“Adherence to Healthy Lifestyle Habits in US Adults 1988-2006”
King, DE, Mainous, AG, et al
Am Jour of Medicine Vol 22, Issue 6 2009
Diabetics have been shown to be deficient in the mineral
chromium.
Is essential to potentiate the insulin receptors
Excessive amounts of chromium picolinate are now
linked to cancer.
Chromium polynicotinate is more effective than any
other type of chromium, as it binds the elemental
chromium to niacin.
This provides a biologically active form of chromium,
which is more absorbable in the body.
Nutrient Density is a measure of nutrients
provided per calorie of food, or the ratio of
the amount of a nutrient in foods to the
energy provided by these foods.
Nutrient-dense foods are those providing
substantial amounts of vitamins and
minerals and relatively fewer calories.
25
THEN
NOW
Balance of saturated and
unsaturated fats
Overly saturated fats
Complex carbohydrates
Simple and refined carbohydrates
High quality plant and animal
protein
Corn-fed beef and poor quality
proteins
Nutrient dense foods supply
vitamins, minerals and
phytochemicals that create
antioxidants.
Chemically and genetically
modified, denatured and
“fortified” foods
CONTROLS INFLAMMATION
PROMOTES INFLAMMATION
Manufactured in the liver (only 25% from food)
Responsible for cellular health, hormone formation
and Vitamin D metabolism.
High Density Lipoprotein (HDL)-removes cholesterol
from the cells and transports back to the liver.
An enzyme that is required for electron transport in ATP
synthesis (facilitates energy production at the cellular
level)
95% of human body’s energy is generated this way!!
Immune system support
Provides antioxidative-bioenergetic balance
Useful in maintaining energy levels
Oxidative protection for cellular membranes and plasma
lipoproteins
Neuro-protective
Low level linked to decreased cardiovascular function
Decreased with statin use!
Low Density Lipoprotein (LDL)- transports cholesterol
and fat from the liver to the cells.
Found in every cell of your body, especially in the
membranes of these cells, where it helps maintain the
integrity of these membranes, and plays a role in
facilitating cell signaling
Molecule for molecule, cholesterol can make up nearly
half of the cell membrane.
Also present in membranes of organelles inside the cells.
About 25% of total body cholesterol is located in the
brain!!
Is the backbone of vitamin D (not really a vitamin)
LDL is harmless. It becomes a problem when
unstable free radicals oxidize it.
When LDL settles on artery walls, the wall
membranes release damaging free radicals.
The resulting oxidized LDL draws white blood
cells to the site. These form plaque and trigger
inflammation of the endothelium.
50% Calcium
3% Cholesterol
26
Statin
Statins only reduce cholesterol in one mannerinhibiting cholesterol production in the liver.
Statins generally focus on lowering LDL but do little to
improve HDL or lower triglyceride levels.
They may lead to dangerous side effects - some
people cannot take statins at all due to these side
effects.
Statins alone may not lower cholesterol to the desired
levels.
They deplete stores of CoQ10, which is a powerful
antioxidant and necessary for proper cell wall
development and cellular energy production.
Red
Statins*
Bile Acid Sequestrants*
Fibric Acid Derivatives*
Niacin (Nicotinic Acid)
Reduce
Cholesterol
Increase
Blood Flow
Depletes
Enzyme CoQ10
CoQ10 Supports
Mitochondria Energy
Production
Depleted Energy
Required For
Cells in Muscles
yeast rice
“Reduction in inflammation has been shown to
have as beneficial an effect in reducing future
cardiovascular events as lowering cholesterol.”
Fiber
Soy
Plant
Sterols
E (tocotrienols)
Intestinal Absorption Inhibitors Fish Oils/Omega-3s
Vitamin
Ridker, PM., et al, C-reactive protein levels and outcomes after statin
therapy, N. Engl. J. Med., 352, 20, 2005
RANK DRUG
Manufacturer Target
1
Lipitor
Pfizer
2
Advair
GSK
Asthma
3
Plavix
Bristol-Myers
Thrombotic Events
4
Nexium
AstraZeneca
GI disorders
5
Norvasc
Pfizer
Hypertension
RANK
CONDITION
# DEATHS
1
Heart Disease
616,067
2
Cancer
562,875
3
Stroke (CV disease) 135,952
4
Respiratory disease 127,924
5
Accidents
123,706
6
Alzheimer’s
74,632
7
Diabetes
71,382
Cholesterol
Not really a vitamin- more like a steroid (a pro-hormone)
Formed from cholesterol!
D3 (cholecalciferol) is 70% more effective than D2
(ergocalciferol)
Regulates calcium and phosphorus levels in blood
(promotes absorption)
Reduces plaque deposits
Promotes phagocytosis, anti-tumor activity and
immunomodulatory functions.
Recommended: about 2,000 IU daily (sun UVB- is best
source)
27
Food
Mushrooms
Fish liver oil
Catfish
Salmon
Mackerel
Sardines, canned
Tuna, canned
Eel, cooked
Whole egg
Beef liver, cooked
Milk*
Orange Juice*
4000–12,000 IU/day
What We Need
Calorie Restriction
Complex Carbohydrates
Reduce Cholesterol
Exercise
Nutrient Dense Foods
Portion Control
Vitamin D3
10-524 IU
1360 IU
425 IU
360 IU
330 IU
250 IU
235 IU
200 IU
60 IU
15 IU
115-124 IU
137 IU
40 to 80 ng/mL
What We Do
Resveratrol
Fortified Foods
Take Statins
“Exercise in a Pill”
Genetically Modified
Food
SUPERSIZE ME!
“Persons receiving 2.5 mg of folic acid, 25 mg
vitamin B6, and .5 mg vitamin B12 showed
regression of atherosclerosis evidenced by a
decrease in the thickness of the arterial wall, while
the those in the placebo group experienced an
increase.”
U Till et al., Decrease of Carotid Intima-Media Thickness in Patients at Risk to Cerebral Ischemia after
Supplementation with Folic Acid, Vitamins B6 and B12, Atherosclerosis, July 2005
Be Critical!
There is no “single bullet”
It matters not what you do once in a
while, but what you do every day.
Balance is needed
because more is not
better…
Thank you
Jeffrey Anshel, OD, FAAO
Corporate Vision Consulting
[email protected]
28