Ocular Nutrition and the Aging Eye
Transcription
Ocular Nutrition and the Aging Eye
Advisory Board Consultancies ◦ TearLab ◦ ◦ ◦ ◦ Biosyntrx, Inc. Bausch + Lomb Vistakon OmniActive Health Technologies Jeffrey Anshel, OD, FAAO Ocular Nutrition Society Ocular Nutrition Society Editorial Advisory Board ◦ President, Founding Director ◦ ◦ ◦ ◦ Optometry Times Primary Care Optometry News Optometric Office Review of Optometry Integrative medicine is a healing-oriented medicine that takes account of the whole person, including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of both appropriate conventional and alternative therapies. A philosophy that neither rejects conventional medicine nor accepts alternative therapies uncritically Use of natural, effective, less-invasive interventions whenever possible Integrative Optometry follows these same principles. Age-adjusted Incidence Rate 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. 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. Females Males 1973 1999 1 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 Macular Degeneration Cataract Glaucoma Dry Eye 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 Formulation: Sponsored the National Eye Institute (NEI) Started in 1988 The trial included 3,780 participants who had at least early AMD 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 Started in 2007- published 2013 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???? “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. 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 Took placebo pills Diabetes- 13% 89% taking Centrum Silver (with some lutein) Few Hispanics (2%) No placebo (AREDS1) 3 Placebo Lutein/Zeaxanthin Original AREDS formula Lutein- 10mg Zeaxanthin- 2mg EPA/DHA L/Z and EPA/DHA EPA- 650mg DHA- 350mg AREDS plus L/Z and EPA/DHA Formulations Vitamin C Vitamin E 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 Progression to Advanced AMD (AAMD) Hazard Ratio Tree Favors Favors Treatment CONCLUSION: “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.” AREDS1 formulation with L/Z but no beta-carotene, their risk of developing advanced AMD … was reduced by about 18%, compared with participants who took an AREDS formulation with beta-carotene but no L/Z. Participants with low dietary intake of L/Z, but who took an AREDS formulation with L/Z during the study, were about 25% less likely to develop advanced AMD compared with participants with similar dietary intake who did not take L/Z. Placebo Lutein/Zeaxanthin p=0.12 DHA/EPA p=0.70 Lutein/Zeaxanthin+DHA/EPA p=0.10 Placebo (reference) 0.7 Probabilities of progression to advanced AMD: Placebo: 31% L/Z: 29% EPA/DHA: 31% L/Z+EPA/DHA: 30% 0.8 0.9 1 1.1 1.21.3 1.21.3 Hazard Ratio (98.7%CI) AREDS2 Research Group. (2013) JAMA, In Press. Progression to AAMD by Primary and Secondary Randomization Main Effects Favors Treatment p = 0.02 L/Z vs. No L/Z p = 0.01 DHA/EPA vs. No DHA/EPA Favors Favors Control Placebo p=0.05 p=0.1 2 p=0.7 0 p=0.1 0 Low Zinc vs. High Zinc BetaBeta-Carotene Yes vs. No 0.8 0.9 1 1.1 1.2 Hazard Ratio (95%CI) AREDS2 Research Group. (2013) JAMA, In Press. 4 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 “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! 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). 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. 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]) 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 “Vitamin D Status and Early Age-Related Macular Degeneration in Postmenopausal Women” Conclusion: High serum 25(OH)D concentrations may protect against early AMD in women younger than 75 years. Yellow, orange, red lipophilic pigments ~ 600 known carotenoids 40-50 in typical human diet 14 found in serum ◦ Lutein Lutein, β-Carotene, Lycopene, α-Carotene, Zeaxanthin, Zeaxanthin β-Cryptoxanthin Amy E. Millen, PhD, et al Arch Ophthalmol. 2011;129(4):481-489 © Kemin Industries, Inc. 2006 All rights reserved. ® ™ Trademarks of Kemin Industries, Inc., U.S.A. 5 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. Increased risk of cancer in smokers and SECOND-HAND smokers! Interferes with the absorption of lutein and zeaxanthin “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 “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 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 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 sub-retinal 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. 7 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!! ©1995-2003 by Michael W. Davidson Delta-T3 GammaT3 Beta-T Beta-T3 Alpha-T AlphaT3 44 Are blocked by tocopherols- especially alphatocopherol Super-antioxidant (anti-cataract) Increases tear production Reduces diabetic retinopathy Targets angiogenesis (AMD) Best source- annatto beans: contain gamma and deltatocotrienol (best for cardio-protection, cancer and diabetes) Fundus alterations: pre treatment 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 Acetyl-L Carnitine: drives CoQ10 across the membrane CoQ10: cleans out the mitochondria (antioxidant) Fundus alterations: post treatment 8 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) 9 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 •Vitamin C “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. “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 Cellini M, et al. Fatty acid use in glaucomatous optic neuropathy treatment. Acta Ophthalmol Scand Suppl . 1998;227:41-42. 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 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 10 “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.” 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. 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% 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) 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% 11 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. 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 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 Omega-3 PUFA 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! 12 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. 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 Statin Reduce Cholesterol Increase Blood Flow Depletes Enzyme CoQ10 CoQ10 Supports Mitochondria Energy Production Statins* Bile Acid Sequestrants* Fibric Acid Derivatives* Niacin (Nicotinic Acid) Red yeast rice Fiber Soy Plant Sterols E (tocotrienols) Intestinal Absorption Inhibitors Fish Oils/Omega-3s Vitamin Depleted Energy Required For Cells in Muscles 13 “Reduction in inflammation has been shown to have as beneficial an effect in reducing future cardiovascular events as lowering cholesterol.” Ridker, PM., et al, C-reactive protein levels and outcomes after statin therapy, N. Engl. J. Med., 352, 20, 2005 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) What We Need Calorie Restriction Complex Carbohydrates Reduce Cholesterol Exercise Nutrient Dense Foods Portion Control What We Do Resveratrol Fortified Foods Take Statins “Exercise in a Pill” Genetically Modified Food SUPERSIZE ME! 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 616,067 562,875 Cholesterol 2 Cancer 3 Stroke (CV disease) 135,952 4 Respiratory disease 127,924 5 Accidents 123,706 6 Alzheimers 74,632 7 Diabetes 71,382 “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.” Decrease of Carotid Intima-Media Thickness in Patients at Risk to Cerebral Ischemia after Supplementation with Folic Acid, Vitamins B6 and B12, U Till et al., Atherosclerosis, July 2005 Be Critical! There is no “magic bullet” It matters not what you do once in a while, but what you do every day. You can’t throw a few pills after a bad diet and expect miracles. Balance is needed because more is not better… 14 Thank you Focusing on Nutrition Education www.ocularnutritionsociety.org Jeffrey Anshel, OD, FAAO Ocular Nutrition Society [email protected] 15
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