Download nutritional options, ho

9/7/11
Introduction
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•  With no effective means of prevention, the
prevalence of ARMD will only increase as
the population ages
•  For these reasons, identification of
inexpensive, safe strategies to prevent
ARMD is paramount
•  Optometry should be at the forefront of this!
AREDS: The Age Related Eye Disease Study
AREDS
Nutritional Options for AMD
!
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•  Objective: To evaluate the effect of high-dose
vitamins C and E, beta carotene, and zinc
supplements on AMD progression and visual
acuity
! 11 center, double-masked study
! 3640 participants, age 55-80
! Average follow-up of 6.3 years
•  Patients divided into 4 categories based on level of
ARMD
–  Category 1: early ARMD
–  Less than 5 small drusen (<63um)
–  Category 2: mild ARMD
–  Multiple small drusen
–  Single intermediate size druse (63-124 um)
–  Category 3: moderate ARMD
–  One large druse (125 um)
–  Extensive intermediate drusen
–  GA not centrally
–  Category 4: advanced ARMD
–  More than one large drusen
–  GA centrally
AREDS: Results
•  25% decrease risk reduction in developing
advanced ARMD in categories 3 and 4 with
antioxidants plus zinc
– 
– 
– 
– 
– 
500 mg vitamin C
400 IU vitamin E
15 mg vitamin A (25,000 IU beta carotene)
80 mg zinc
2 mg copper
•  Due to low progression to advanced ARMD in
categories 1 and 2, unable to show benefit
•  No statistically significant effect on cataracts
AREDS: Shortfalls
•  No apparent benefit in category 1 and 2
–  80% fall into this group
•  Unsure how long someone at risk should
continue supplements
•  Beta carotene associated with increased risk of
lung cancer in smokers
–  substitution of other antioxidants (lutein) is unclear
–  how long a non-smoker is debatable
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AREDS: Shortfalls
•  Did not evaluate the role of lutein/zeaxanthin,
or omega 3 s
–  AREDS 2 underway, but may be several years till
results are in
•  Benefit is modest, and all groups had
progression despite treatment
•  The supplements are not a cure for ARMD,
nor will they restore vision already lost from
the disease
AREDS: Take home
•  Reasonable to suggest antioxidant plus zinc in
patients with moderate to severe ARMD
•  No proven benefit in early to mild ARMD
•  Increased risk of lung cancer with beta
carotene should be considered in smokers and
past smokers
–  AREDS press release 10/2001
Lutein and Zeaxanthin
•  Naturally occurring carotenoids that are found
in high concentration in the eye, specifically
the macula/retina
•  Many feel protective for ARMD
–  Absorbing blue light
–  Quenching free radicals
–  Increasing membrane stability
Lutein and Zeaxanthin
•  Several smaller studies have shown positive benefit of Lutein
and/or Zeaxathanin
–  Seddon Study, 1994: Evaluated dietary carotenoids, vitamins A, C and
E
•  356 pts
•  Pts with highest dietary intake of carotenoids (specifically lutein and
zeaxanthin) had a 43% lower risk for ARMD than those with lowest levels
–  LAST Study: Stuart Richer, Optometry, April 2004
•  90 pts, mostly male
•  Increased MPOD, increase VA, glare recovery, contrast sensitivity in pts
taking L and L plus antioxidnants vs. placebo
–  LUXEA Study: 2006
•  92 pts taking L, Z, C, or P
•  Small (13%) in MPOD among pts taking L
Lutein and Zeaxanthin
Meso-zeaxanthin
•  Cumulative effect of studies seem to indicate a
positive effect of Lutein as well as Zeaxanthin
on MPOD and ARMD
•  No single, large scale study like AREDS yet
done
•  MZ is the dominant carotenoid in the central
fovea
•  Of the three macular carotenoids, MZ is the
most powerful antioxidant
•  MZ facilitates a wider range of blue light
filtration
•  Ideally located to afford protection against free
radical damage
–  Will be evaluated in AREDS 2
•  Dosage: 10 mg Lutein, 4 mg Zeaxanthin
2
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Fish Consumption and Omega-3 Fatty
Acids
•  Conflicting studies in the literature
Fish Consumption and Omega-3 Fatty
Acids
•  Conflicting studies in the literature
–  Seddon et al, Ophth 2004: 60% reduced risk to advanced
ARMD for people who w/ highest fish consumption (> 2
times /wk)
–  Ophthalmology, July 2006: issue of protective nature
neither clearly supported nor refuted
–  Arch Ophthalmology, July 2006: US Twin study showed
that fish consumption and omega-3 fatty acids intake
reduced the risk of ARMD
–  Arch Ophthalmology, July 2006: a diet high in omega 3
fatty acids , especially from fish, suggests protection
against early and late in Australian patients
–  AREDS Report No. 20: 40-50% reduced likelihood of
advanced neovascular ARMD in pts with highest levels of
omega-3 consumption
–  AREDS Report No. 23: 50% decreased likelihood of
progression to central GA with highest level of omega 3/FA
consumption
–  The American Journal of Clinical Nutrition, August 2008:
eating oily fish at least once per week reduced risk of
neovascular ARMD by half
Fish Consumption and Omega-3 Fatty
Acids
•  Bottom line: unclear, however omega 3 and
DHA/EPA do seem protective
–  1000 mg/day
–  At least 2/3 DHA and EPA
•  Need to await results of AREDS 2 to know for
sure (hopefully)
•  Suggest oily fish and least once per week?
–  Salmon, trout, sardines, mackerel, herring,
anchovies, swordfish, fresh tuna
B&L PreserVision™
•  OTC formulation by B&L
•  Several Formulations:
–  Original, soft gel ,and Lutein
Other vitamins
• 
Co-Q 10
–  A coenzyme produced by the body and required for basic function of all cells
–  Used in neurology
–  Studies are inconclusive
• 
Lycopene
–  Another carotenoid found in red fruit and vegetables such as tomatoes, guava,
watermelon, pink grapefruit and papaya
–  Helpful for prostate issues in men
–  Unknown effect in ARMD
• 
Taurine
–  Some studies indicate that due to its high concentration in the eye, may play a protective
role in ARMD
–  In cats, taurine deficiency has been shown o cause retinal degeneration
–  Speculative only at this point
• 
Acetyl-l-carnitine
–  Many have anti-oxidant as well as anti-aging properties
–  Role in ARMD unknown
B&L AREDS 2 Formula
•  Based on Original
AREDS formula plus
new evidence
–  No Beta-carotene
–  1000 mg omega 3
•  350 DHA, 650 EPA
–  10 mg Lutein
–  2 mg zeaxanthin
•  2 soft gels BID
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9/7/11
B&L AREDS 2 Formula
ICAPS®
•  Developed and marketed by Alcon
•  Three formulations: AREDS, Lutein &
Zeaxanthin, and MV
–  Now in soft-gel as well
AREDS Multivitamin Compositions
Theoretical
AREDS1
ICAPS®
AREDS
(Labeled Amount)
(Actual Amount)
2 tablets,
twice daily
2 tablets,
twice daily
1 tablet, once daily
2 tablets,
twice daily
Daily Dosage
Daily Dosage
Daily Dosage
Daily Dosage
15 mg
(25,000 IU)
17.2 mg
(28,640 IU)
2.1 mg
(3,500 IU)
(29% as Beta Carotene)
!
Vitamin C
500 mg
452 mg
60 mg
512 mg
Vitamin E
400 IU
400 IU
45 IU
430 IU
Zinc
80 mg
69.6 mg
15 mg
84.6 mg
Copper
2 mg
1.6 mg
2 mg
Lutein
-
!
250 mcg
Ingredient
Centrum
Silver*
ICAPS® Ocular Vitamins
ICAPS®
MV*
(Actual Amount)
Lutein & Zeaxanthin Formula
1 tablet, twice daily
Daily Dosage
Vitamin A
(Beta-Carotene)
Zeaxanthin
Omega-3 s
!
!
!
!
Vitamin A (beta-carotene)
6,600 IU
Vitamin C
400 mg
Vitamin E
150 IU
Zinc
60 mg
Copper
4 mg
Lutein/Zeaxanthin (combined)
4 mg
(4,000 mcg)
3.6 mg
Riboflavin (Vitamin B2)
10 mg
6.7 mg
Calcium
30 mg
Selenium
40 mcg
Manganese
10 mg
3.3 mg
!
!
•  Best for pre-ARMD patients
* Both Centrum and ICaps® MV contain other less important ingredients at the
RDA s.
ICAPS® Ocular Vitamins
ICAPS® MV Multi-Vitamin
2 tablets, twice daily
Daily Dosage
Vitamin A (Betacarotene)
AREDS Formula
AREDS Formula
2 tablets, twice
daily
1 softgel, twice
daily
Daily Dosage
Daily Dosage
28,640 IU (100%
as Beta
Carotene)
Vitamin A (beta-carotene)
Folic Acid
400 mcg
Vitamin C
512 mg
-
Vitamin B12
6 mcg
Vitamin E
430 IU
Biotin
30 mcg
28,640 IU (100%
as Beta
Carotene)
Lutein
6.67 mg
Pantothenic Acid
10 mg
Zinc
84.6 mg
Calcium**
300 mg
3.6 mg
Phosphorus
140 mg
Vitamin C
452 mg
452 mg
Copper
Vitamin E
400 IU
400 IU
Zeaxanthin
3.33 mg
Iodine
150 mcg
Zinc
69.6 mg
69.6 mg
Vitamin D
400 IU
Magnesium
100 mg
Copper
1.6 mg
1.6 mg
Vitamin K
25 mcg
Selenium
40 mcg
Thiamin
1.5 mg
Manganese
2 mg
Riboflavin (Vitamin B2)
10 mg
Chromium
120 mcg
Niacin
10 mg
Molybdenum
75 mcg
Vitamin B6
2 mg
Lycopene
0.3 mg
Calcium
132 mg
Best for ARMD stage 3,4
• 
Best for smokers or pts who want only 1 vitamin
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9/7/11
New ICAPS® Lutein and Omega-3
ICAPS® Lutein & Omega Active
Ingredients
•  Ideal Combination of Ingredients for General
Eye Health and patients at risk of AMD:
Actives
Vitamin A (beta-carotene)
Vitamin A (retinol)
Vitamin C
Vitamin E
Vitamin B1 (Thiamin)
Vitamin B2 (Riboflavin)
Vitamin B3 (Niacin)
Vitamin B6
Vitamin B9 (Folic Acid)
Vitamin B12 (Cyanocobalamin)
Zinc
Selenium
Copper
Manganese
Lutein (Zeaxanthin)
Zeaxanthin
Omega -3 Fatty Acids
•  One Softgel Daily
–  10 mg of Lutein
–  2 mg of Zeaxanthin
–  280 mg Omega-3
–  B Vitamins
–  No Beta-carotene
•  Best for early, or at risk pts
•  One per day!!
ICaps® Lutein &
Omega
1 Per Day
Daily Dosage
ICaps® Lutein &
Omega
% RDA
Daily Dosage
600 mcg
45 mg
10 mg
1.2 mg
1.3 mg
16 mg
1.3 mg
240 mcg
2.4 mcg
7 mg
34 mcg
0.9 mg
2.3 mg
10 mg
2 mg
280 mg
20%
75%
50%
80%
76%
80%
65%
60%
40%
47%
49%
45%
115%
*
*
*
*Percent Daily Value not Established
Maxivision
LMZ3 by MacuHealth
452mg C
400IU E
69.6mgZ
•  1 capsule daily with a meal
– 10 mg Lutein
– 10 mg Meso-zeaxanthin
– 2 mg zeaxanthin
1.6mg Cu
•  Doctor driven and sold
•  Claims to have highest level of
lutein
$20/60 pills
Dr. Bob Martin s OptiAll
Premier Formula for Ocular Nutrition
28,640IU A
452mg C
• 
400IU E
• 
69.6mgZ
• 
• 
1.6mg Cu
• 
• 
• 
• 
• 
•  Close to AREDS
•  Expensive: $90/200pills
• 
–  50 day supply
•  Adds Taurine and Lutein
• 
Carnosine reduces the risk of cross-linking (the process in which protein and glucose starts sticking
together) which increases the risk of eye degeneration.*
Astaxanthin is 100 times more effective at inhibiting lipid peroxidation than is Vitamin E.* Other
tests have shown that Astaxanthin is up to 1000 times more powerful than Vitamin E.* A recent study
shows that Astaxanthin is effective at protecting the retinal, and that it is also effective at protecting
photoreceptors,* and easily crosses the blood-brain barrier (unlike Beta-Carotene).
Vitamins C, E, A, Beta Carotene, Zinc and Selenium significantly cuts the risk of vision and eye
concerns, says a recent groundbreaking study.
Lutein and Zeaxanthin protect the macula region of the eye (the area responsible for detailed vision)
from free radical damage and retard age-related eye concerns.*
Rutin and Quercetin are excellent antioxidants utilized in the body to enhance the effectiveness of
Vitamin C, and help strengthen the walls of the intricate blood vessels in the eye.*
Taurine is an amino acid that is important for the maintenance of healthy tissues of the retina. It helps
protect the eyes from harmful effects of ultraviolet light.*
N-Acetylcystein (NAC) is a major glutathione precursor. Glutathione has antioxidant activity which
may promote healthy eyes, and is crucial in protecting against free radical damage.*
Alpha Lipoic Acid (ALA) is a vitamin-like antioxidant that supports good vision and eye health by its
antioxidant protection and its ability to regenerate and increase Vitamins C and E in the body.*
Gingko is a powerful herbal extract that may increase the circulation of blood to the eyes, and has
shown to help lower intraocular pressure in the eyes. It has antioxidant activity, improves arterial blood
flow and enhances cellular metabolism.*
Bilberry has antioxidant and anti-inflammatory effects, and strengthens the structural integrity of blood
vessels throughout the body and promotes healthy circulation, particularly to the small capillaries that
deliver oxygen and nutrients to the eyes.* Bilberry also helps prevent free radical damage to the
delicate structures within the eye, and may help your night vision and adaptation to the dark, and
promote visual acuity and capillary integrity.*
Other Beneficial Natural Ingredients: Rutin, Eyebright, Green Tea Extract, Vitamins B-2 and B-6.
2 tablets/BID
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9/7/11
Ocular Lutein Formula Spray
Dose:
6 sprays per day for the first two months then
3 sprays per day for the next two months and
lastly
1 spray per day as a preventative
Form:
Spray
Pack size:
Availability:
Each bottle contains 30ml (approximately 180 sprays)
Ordered as required - usually dispatched within 1
week
6 sprays (approx 1ml) of Ocular Spray provides the
following:
Vitamin B3-Niacin
5.0mg
Vitamin E
4IU
Lutein
1.25mg
Coleus Forskohlii
6.25mg
Tylophora Asthmatica
6.25mg
Zeaxanthin
0.1mg
Gingko Biloba
Are People using AREDS
Supplementation?
69.84%
AREDS
11.83%
4.64%
Other
Lutein Alone
0.93%
0.00%
20.00%
•  Several reports indicate that patients are not
taking vitamins
–  42% (13/31) of patients eligible for
supplementation were taking it properly if at all
–  these were patients who had it recommended and
discussed with doctor and staff
–  Australian study: 58% of eligible ARMD patients
had heard of vitamins, 38% were taking, but only
1% taking correctly
12.76%
C, E, Zinc & Lutein
•  Is AREDS supplementation standard of care?
•  YES!!!
•  2009 study of American Society of Retina
Specialists revealed almost 70% of Retina
Specialists recommend AREDS
supplementation for AMD patients with high
risk non-exudative disease
1mg
Retinal Specialist Vitamin
Recommendations
C, E, Zinc, Lutein &
Zeaxanthin
Question?
40.00%
60.00%
80.00%
•  Why ?
American Society of Retina Specialists, Preference and Trends Survey 2009 434 Retina Specialists – What vitamin regimen for
AMD patients with high risk non exudative disease do you recommend?
Are People using AREDS
Supplementation?
•  Confusion:
–  At least 400 products for the eye
•  About 50 4-5 yrs ago
–  many different brands that may or may not have correct
dosages
•  Cost
–  $20/30 day supply
–  $240/year
•  Not all providers are advocates of AREDS
supplementation
Cost effectiveness of Vitamin Therapy
•  July 2007, Ophthalmology
•  Computer based model
•  Concluded that improves quality of life in
ARMD patients at a reasonable cost
•  Also stated should be a high public health
preventive measure
–  As high as breast cancer screening in woman >50
and vision screening in children to detect
strabismus and amblyopia at 85% compliance
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9/7/11
AREDS 2
•  AREDS 2: Enrollment ended June 2008 with patients
to be followed for six years
–  Effect of lutein, zeaxanthin and omega 3 on ARMD
–  Effect of eliminating beta carotene on ARMD
–  Effect of reducing zinc on ARMD
–  Effect of supplements on cataracts
–  Validate the ARMD scale from original AREDS
•  Results may not be available for 3-4 more years
Vitamins: Take Home
Vitamins: Take Home
•  Use AREDS formulation in suitable patients
•  Encourage proper dosing
•  Discourage use of similar products that differ
from AREDS formulation
–  Recommend what you want patient to take!
•  Review literature to determine value of other
supplements, especially lutein, zeaxanthin, and
omega-3 s
Conclusion
•  The best intake is through diet/food
–  Not always realistic:
–  Average American gets only 2mg Lutein
–  Leading antioxidants for average American is coffee
–  French fries account for 25% of all vegetable intake in US
–  Vitamin E 13x, A and C 5x recommended daily dose
–  Only 3% of Americans follow 4 basic health
practices
No smoking
BMI 18.5 – 25
5 or more FRUITS & VEGATABLES daily
> 30 minutes physical activity/ 5x times wk
•  Discuss AREDS with all ARMD patients
•  Take AREDS formulation unless contraindicated in
stage 3,4
•  Tell patients which product you recommend and
WHY!!!
•  Discuss pros/cons in other pts with ARMD but not
3,4
•  Discuss prevention in high risk patients
–  Consider lutein, omega 3 s in these patients
7