ASCRS ♦ ASOA Symposium & Congress

Technicians & Nurses Program

April 17-21, 2015 – San Diego, California

1

Jeffrey Anshel, OD, FAAOCorporate Vision Consulting

� Advisory Board◦ Tear Lab, Inc.

� Speaker’s Bureau◦ Pure Encapsulations

◦ Biosyntrx, Inc.

◦ Vistakon

◦ Bausch & Lomb

� Ocular Nutrition Society◦ Past-President, Founding Director

� Editorial Advisory Board◦ Optometry Times

◦ Primary Care Optometry News

◦ Review of Optometry

◦ Optometric Office

� 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.

“We don’t have a healthcare system here in the US; we have a disease management system- and it doesn’t work!”

Andrew Weil, MD

� 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

Nutraceutical can be defined as, “supplement that provides medical or health benefits, including the prevention and/or treatment of a specific disease."

However, the term nutraceutical as commonly used in marketing has no regulatory definition.

2

Dietary Supplement: a product taken by mouth that contains a dietary ingredient that may include vitamins, minerals, herbs or other botanicals, amino acids and substances such as enzymes, organ tissues, glandulars and metabolites.

Disclaimer: “These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, cure, prevent or treat any disease”

“Manufacturers are not responsible for safety or effectiveness”-Really??

Common Misconceptions

� They are “natural”, so completely safe

� They are ineffective (“only vitamins”)

� They are all the same

� If some is good, more is better

� June 2002 - The American Medical Association now recommends that all persons take a well formulated multiple vitamin/mineral supplement.

� January 2008- Healthcare Professionals Impact Study found that 72% of physicians and 89% of nurses use dietary supplements. Additionally, 79% of all physicians and 82% of all nurses now recommend dietary supplements to their patients.

� 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.

� Over 50 peer-reviewed studies link excess weight to an increase in chronic eye disease.

� We die too slowly from chronic processes like stroke, heart disease, cancer, diabetes, Alzheimer’s and Parkinson’s.

� We have a long “life span” but a shorter “health span”.

� Macular Degeneration

� Dry Eye Syndrome

� Cataract

� Glaucoma

� Diabetes/Diet

A condition in which the cells of the macula lutea degenerate, resulting in blurred vision and ultimately blindness

3

� Age

� Gender

� Hyperopia

� Genetic predisposition

� Smoking*

� Blue light exposure*

� Nutrition*

� Obesity*� Cardiovascular Disease*� Hyperlipidemia*� Hypertension*

� Sponsored the National Eye Institute (NEI)

� Started in 1988

� The trial included 3,640 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.

� The study was not designed to evaluate participants who initially had no AMD (Category I).

� The study confirmed this low risk -- participants with no AMD had less than a one percent chance of losing vision from AMD during the study.

� 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.

4

American Society of Retinal Specialists; Preference and

Trends Survey, 2009

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

Formulations Vitamin C Vitamin E Beta-carotene Zinc OxideCupric

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

Placebo Lutein/Zeaxanthin EPA/DHA L/Z and

EPA/DHA

Original AREDS formula

Lutein- 10mgZeaxanthin- 2mg

EPA- 650mgDHA- 350mg

AREDS plus L/Z and EPA/DHA

AREDS 1AREDS 1AREDS 1AREDS 1 AREDS 2AREDS 2AREDS 2AREDS 2

Younger- avg. age 69 Older- avg. age 74

All AMD stages Sicker- stage ¾

Typical SAD diet “Well-nourished”

Diabetes- 7% Diabetes- 13%

67% taking Centrum Silver (no lutein)

89% taking Centrum Silver (with some lutein)

Demographic- unclear Few Hispanics (2%)

Took placebo pills No placebo (AREDS1)

� “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.”

� Does NOT address prevention or reversal!

5

� 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.

Lutein Antioxidant Supplement Trial� 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.

� At 7.3 years of follow-up, reports had turned up 82 cases of AMD among women taking placebos and only 55 cases in the women receiving the high- potency B vitamin supplements.

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.

Amy E. Millen, PhD, et al

Arch Ophthalmol. 2011;129(4):481-489

� Yellow, orange, red lipophilic pigments

� ~ 600 known carotenoids

� 40-50 in typical human diet

� 14 found in serum◦ Lutein, β-Carotene, Lycopene,

α-Carotene, Zeaxanthin, β-Cryptoxanthin

Lutein

Zeaxanthin

© Kemin Industries, Inc. 2006 All rights reserved. ® ™ Trademarks of Kemin Industries, Inc., U.S.A.

Ong and Tee (1992). Methods in enzymology 213:142-167.

Khachik F, Beecher GR, Goli MB, Lusby WR (1992). Methods Enzymol 213:347-359.

Khachik F, Beecher GR, Goli MB, Lusby WR, Daitch CE (1992). Methods Enzymol 1992, 213:205-219.

� 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

6

�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.

© Kemin Industries, Inc. 2006 All rights reserved. ® ™ Trademarks of Kemin Industries, Inc., U.S.A.

U.S. Department of Agriculture, Agricultural Research Service. 2003. USDA National Nutrient Database for Standard

Reference, Release 16. Nutrient Data Laboratory Home Page, http://www.nal.usda.gov/fnic/foodcomp

Food itemmg lutein & zeaxanthin

per 100 g

Kale, raw 39.5

Spinach, raw 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 0.3

Whole eggs, raw 0.3

Oranges, raw 0.1

Tomatoes, raw 0.1

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 study, 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 (included in AREDS) 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.

7

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 40mg per day for adults over 19.

� 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)

� A long history of heart disease, stroke or diabetes,

� They 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.

� A significant percentage were also cigarette smokers!!

39

Vitamin E Family

Tocopherol (T) Tocotrienol (T3)

Alpha-T

Beta-T

Gamma-T

Delta-T Delta-T3

Gamma-T3

Beta-T3

Alpha-T3

Vitamin E

©1995-2003 by Michael W. Davidson

� 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: blocks metabolic conversion to pro-inflammatories

◦ Acetyl-L Carnitine: drives CoQ10 across the membrane

◦ CoQ10: cleans out the mitochondria (anti-oxidant)

Fundus alterations: pre treatment

Fundus alterations:post treatment

� Omega 3 fatty acid derived from alpha-linolenicacid

� Abundant in the retina◦ Concentrated in the rod outer segments◦ Highest concentration of any cell type in the body.◦ Constitutes 30-40% of total fatty acid in the retina/brain- far

more than any other tissue.

� 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

8

� An enzyme that is required for electron transport in ATP synthesis (facilitates energy production at the cellular level)

� 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!

� Anecdotal evidence of improved night vision of pilots in WWII.

� Since the structure of anthocyanins is consistent with an ability to donate hydrogen atoms, it has been concluded that these compounds have powerful antioxidant capability.

� Accordingly, anthocyanins have been shown to scavenge chemically-generated superoxide and nitric oxide radicals, as well as quench singlet oxygen.

� Also a blood thinner, so moderation is suggested.

� Dry Eye Syndrome (DES) is a disorder of the tear film due to either diminished tear production or excessive tear evaporation.

Mild SevereModerate

Tear Film

Destabilization (Loss of Protection)

Desiccation ofOcular Surfaces

Inflammation

Cytokines•Ocular Surfaces

•Epithelium

•Lacrimal Gland

Injurious Agents•Free Radicals•Toxins•Microbes•Allergens

� Environment

� Age

� Gender

� LASIK

� Lid Abnormality

� Computer Vision Syndrome

� Systemic Medications

� Chronic Diseases

� Contact Lens

Omega-3

Omega-3

Omega-3 Omega-3

Omega-3

OmegaOmegaOmegaOmega----3333

Omega-3

9

Is dry eye an indicator of systemic essential fatty

acid deficiency or imbalance ?

Oil Omega-3 Omega-6 Gamma-

Linolenic

Acid (GLA)

FLAX 85% 15% NONE

EPO NONE 75% 9%

Borage 75% NONE 23%

Black

Currant Seed Oil15% 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 anti-inflammatory

� 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.

“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.”

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

10

� 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.

� Prospective Health Assessment of Cataract Patients’ Ocular Surface

� Nine clinical sites

� 25 patients at each site; 55+ y/o

� Evaluated for dry eye prior to cataract surgery

� Majority of patients have significant signs of dry eyes.

After LASIK, 50% of patients develop common dry eye symptoms, and 10% evolve to more severe disturbances, such as fluctuation of vision, glare and severe discomfort.

Dr Beatrice Cochener

ESCRS Keynote, Feb. 2011

“Dry eye and visual aberrations were increased by both PRK and LASIK in the early post-operative period but normalized by 12 months. PRK caused greater visual aberrations than LASIK immediately post-op.”

Prospective Randomized Comparison of Postoperative Dry Eye and Visual Aberrations in PRK and LASIK

Y. Murakami; E. Manche

IVOS, 2010

Ascorbic acid levels in human tears after photorefractive keratectomy, transepithelialphotorefractive keratectomy, and laser in situ keratomileusis

CONCLUSION: After PRK, transepithelial PRK, and LASIK, the ascorbic acid levels of the tear fluid decreased significantly. Because ascorbic acid is the major scavenger of superoxide radicals in tears, topical ascorbic acid therapy may help eliminate the harmful effect of free radicals from excimer laser surgery.

J Cataract Refract Surg 2001; 27: 585–588

11

As compared with clinical risk factors alone, commongenetic variants associated with the risk of diabetes had asmall effect on the ability to predict the future developmentof type 2 diabetes.

� N Engl J Med. 2008;359:2208-2219.

Number of Number of Number of Number of Diabetic AmericansDiabetic AmericansDiabetic AmericansDiabetic Americans

� Diabetics: 20 million

� Metabolic Syndrome: 60 million

� Two million adolescents (or 1 in 6 overweight adolescents) aged 12-19 have pre-diabetes

2002 2007Direct medical

costs$92 Billion $105.7 Billion

Medication $6.7 Billion $14.9BillionIndirect Costs $40 Billion $53.8 Billion

Total $132 Billion $218 Billion

12

� 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.

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.

“…this shows an association of consuming a diet rich in DHA with lower progression of early AMD.”

In addition to the AREDS supplement, lower dGIwith 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.

1. How many of you eat a diet that provides all the necessary nutrients (vitamins, minerals and antioxidants)?

2. How many of you feel that most of your patients eat a diet that provides all the necessary nutrients?

3. How many of you are even asking?

The new CDC recommendation is 9-13 ServingsA Day To

Prevent ChronicDegenerative Disease

Over 75% of the population eat 3 or less servings a day

Source: CDC Healthy People 2005

Colorful diet

13

Healthy Habit 1988-1994 2001-2006

Body Mass Index >30 28% 36%

Physical Activity 12x per mo. 53% 43%

Smoking 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

� Very high glycemic index food

� Farm subsidies- farmers paid to grow corn

� In just about every commercial food◦ Fried foods- corn oil

◦ Dressings- high fructose corn syrup

◦ Bakery- hydrogenated corn oil

◦ Meat- corn-fed beef; poultry, pork

◦ Fish- farm-raised fish (fed corn meal)

◦ Cereals- corn meal, modified corn starch

◦ Ethnic- corn tortillas; corn bread

PROMOTES INFLAMMATION

THENTHENTHENTHEN

Balance of saturated and unsaturated fats

Complex carbohydrates

High quality plant and animal protein

Nutrient dense foods supply vitamins, minerals and phytochemicals that create antioxidants.

NOWNOWNOWNOW

Overly saturated fats

Simple and refined carbohydrates

Corn-fed beef and poor qualityproteins

Chemically and geneticallymodified, denatured and “fortified” foods

CONTROLS INFLAMMATION

What We Need What We Do

Calorie Restriction Resveratrol

Complex Carbohydrates Fortified Foods

Reduce Cholesterol Take Statins

Exercise “Exercise in a Pill”

Nutrient Dense Foods Genetically Modified Food

Portion Control SUPERSIZE ME!

14

Centrum Silver Ingredients:

Serving Size: 1 Tablet

Each Tablet Contains - % Daily Value:

Vitamin A 3500 IU (29% as Beta Carotene) - 70%,

Vitamin C 60 mg - 100%,

Vitamin D 400 IU - 100%,

Vitamin E 45 IU - 100%,

Vitamin K 10 mcg - 13%,

Thiamin 1.5 mg - 100%,

Riboflavin 1.7 mg - 100%,

Niacin 20 mg - 100%,

Vitamin B6 3 mg - 150%,

Folic Acid 400 mcg - 100%,

Vitamin B12 25 mcg - 417%,

Biotin 30 mcg - 10%,

Pantothenic Acid 10 mg - 100%,

Calcium 200 mg - 20%,

Phosphorus 48 mg - 5%,

Iodine 150 mcg - 100%,

Magnesium 100 mg - 25%,

Zinc 15 mg - 100%,

Selenium 20 mcg - 29%,

Copper 2 mg - 100%,

Manganese 2 mg - 100%,

Chromium 150 mcg - 125%,

Molybdenum 75 mcg - 100%,

Chloride 72 mg - 2%,

Potassium 80 mg - 2%,

Boron 150 mcg - *, Nickel 5 mcg - *, Silicon 2 mg - *,

Vanadium 10 mcg - *, Lutein 250 mcg - *, Lycopene 300

mcg - *.

*Daily Value not established

Dibasic Calcium Phosphate, Calcium Carbonate,

Potassium Chloride, Microcrystalline Cellulose,

Ascorbic Acid (Vit. C), Magnesium Oxide, dl-

Alpha-Tocopheryl Acetate (Vit. E), Modified

Food Starch. Contains < 2%: Acacia,

Anhydrous Citric Acid, Ascorbyl Palmitate,

Beta-Carotene, Biotin, Boric Acid, BHT,

Calcium Pantothenate, Calcium Stearate,

Cholecalciferol (Vit. D3), Chromium Picolinate,

Corn Starch, Crospovidone, Cupric Sulfate,

Cyanocobalamin (Vit. B12), dl-Alpha-

Tocopherol, FD&C Blue No. 2 Aluminum

Lake, FD&C Red No. 40 Aluminum Lake,

FD&C Yellow No. 6 Aluminum Lake , Folic

Acid, Gelatin, Hydrogenated Palm Oil,

Hypromellose, Lutein, Lycopene, Manganese

Sulfate, Medium-Chain Triglycerides,

Niacinamide, Nickelous Sulfate, Phytonadione

(Vit. K), Polyethylene Glycol, Polyvinyl

Alcohol, Potassium Iodide, Pregelatinized Corn

Starch, Pyridoxine Hydrochloride (Vit. B6),

Riboflavin (Vit. B2), Silicon Dioxide, Sodium

Ascorbate, Sodium Benzoate, Sodium Borate,

Sodium Citrate, Sodium Metavanadate, Sodium

Molybdate, Sodium Selenate, Sorbic Acid,

Sucrose, Talc, Thiamine Mononitrate (Vit. B1),

Titanium Dioxide, Tricalcium Phosphate,

Vitamin A Acetate (Vit. A), Zinc Oxide.

May also contain < 2%: Maltodextrin, Sodium

Aluminum Silicate

“I think I got all the vitamins the eye doctor told me to get…”

� More than half the US adult population uses dietary supplements.

� Most supplement users take them every day.

� Supplements can fill gaps in nutrient intake.

� Potential health benefits are substantial.

Why recommend a supplement for your patients that only supports their eyes, if you can recommend one supplement that also slows the progression of all chronic degenerative diseases and supports the prevention of vascular disease, diabetes and cancer?

15

� 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…

Focusing on Nutrition Education

www.ocularnutritionsociety.org

Jeffrey Anshel, OD, FAAO

Corporate Vision Consultingwww.cvconsulting.com

eyexam@cox.net

Thank you