H E A LT H B E N E F I TS O L U T I O NS

W H I T E PA PE R

January 2018

Upgrade your vision: nutritional solutions to improve eye health across the lifespan

VISUAL IMPAIRMENT: INCREASED PRESSURE ON EYE CARE SERVICES

EXECUTIVE SUMMARY

FOREWORD

Eye health continues to be an increasingly difficult challenge for healthcare services worldwide. Not only does every life stage have a different set of risk factors, but the ongoing threat of blue light from sunlight, and increasingly from digital devices, is causing concern for people of all ages. The cost of treatment and rehabilitation for eye conditions, such as AMD, is high, and it is expected to rise even further with the rapidly aging population.

There are a number of non-modifiable risk factors that influence eye health, such as age and genetics. For example, more than 70% of an individual’s risk may

Our current reliance on technology has meant that we are constantly looking at digital devices – both at home and at work. However, staring at our screens has the potential to cause eye strain, and research highlights the growing links between blue light and poor visual health.

As people are becoming more aware of the threats to eye health and visual performance, questions are being raised on the impact the digital age will have on our eyesight in the

future. This, together with the increased risk of age-related macular degeneration (AMD) in older populations, has resulted in visual health now being recognized as the number one concern among consumers globally.

Not only does visual impairment have a negative – and potentially life-changing – effect on the individual, but it can also put a strain on the economy and society as a whole. Furthermore, the economic toll looks likely to increase with the rapidly aging population,

placing an even greater burden on healthcare systems across the world.

While comprehensive eye tests can effectively detect chronic conditions, there are several emerging scientific studies on preventative approaches, such as nutrition. As such, dietary supplements and food and beverage fortification are receiving growing attention for their potential to meet individuals’ visual health needs at different life stages.

Dr Manfred EggersdorferProfessor of Healthy Aging at the University Medical Center Groningen and Senior Vice President and Head of Nutrition, Science and Advocacy at DSM Nutritional Products

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be attributed to specific genetic polymorphisms.2 However, there are also several modifiable risk factors, like smoking and specific supplement use. There is an opportunity for the

The World Health Organization (WHO) defines visual function on four levels, according to the International Classification of Diseases-10:1

1. Normal vision

2. Moderate visual impairment

3. Severe visual impairment

4. Blindness

Despite the overall number of individuals with visual impairment from infectious diseases worldwide decreasing in the last 20 years, eye health continues to be a threat to today’s society and economy (figure 1). There are 285 million people estimated to be visually impaired worldwide, of which 39 million are blind, and 246 million have low vision.3 These figures are predicted to rise further still, due to the aging population.

Figure 1: The main causes of visual impairment are:4

Unoperated cataract

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Corneal opacities

Trachoma

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AMD

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identification of modifiable risk factors to form part of a preventative approach.

Significant research indicates the potential role nutrition can play in the protection of eye health across all age ranges. Emerging studies show the benefits of lutein and zeaxanthin, omega-3 fatty acids and several vitamins in supporting visual development, protection, performance, and eye comfort. This white paper outlines the evidence, role and mechanism of these key nutrients, and uses the latest science to demonstrate how improved nutrition could benefit both individuals’ health and wider society.

AGE-RELATED MACULAR DEGENERATION: A COMPLEX EYE CONDITION

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AMD is a progressive eye disease, and the main cause of blindness in industrialized countries. It was estimated that in 2010 there were 2.07 million people with AMD in the United States, and this is expected to reach 5.44 million by 2050 (figure 2).5 There are two types of AMD: wet (atrophic) and dry (neovascular). Most cases of AMD start as dry, and in 10-20% of individuals it progresses

to the wet type, which can result in rapid and severe loss of central vision. Wet type AMD accounts for approximately 90% of all cases of severe vision loss from the disease.6 AMD is also always bilateral – occurring in both eyes – but it can progress at different rates.7

While there have been extensive studies on this topic, AMD has only recently been

considered an inflammatory disease, rather than a degenerative aging condition. As more research has come to light, there have been several scientific breakthroughs on the prevention, pathogenesis and treatment of AMD. These further studies have highlighted the role that genetic predisposition and environmental factors, such as smoking and diet, can play as risk factors for AMD.8

KEEPING AN EYE ON VISUAL HEALTH ACROSS THE LIFE STAGES

Figure 3: Eye health is the main health concern among adults globally12

How much do you worry about the following?

View from consumersEye health remains a primary concern for adults. A recent DSM survey of 7,541

consumers across 10 countries worldwide found that 70% of adults worry about their visual health ahead of other concerns, such as energy

levels and weight (figure 3). This is more prominent in Latin

America, where 87% of consumers rank eye health as a key concern.11

0 10 20

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30

* Less among mature adults** More among older age groups

40 50 60 70 80 90 100

Eye health (including eyesight) 70%

Energy levels/tiredness* 69%

Protection againstdisease later in life** 67%

Figure 2: Predicted figures for AMD prevalence around the world9

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2010 20351.4m 2.8m +97%2.1m 3.1m +52%3.4m 8.1m +140%1.7m 4.2m +146%

Visual impairment is most prevalent in the elderly generation. According to WHO, 82% of people living with blindness are aged 50 years and above.10 With an increasingly elderly

demographic, the number of people with visual impairment as part of the aging process is likely to rise even further. However, visual impairment can affect individuals at all ages,

with the risk factors varying greatly between the life stages. As a result, following a life course approach is key in the maintenance of visual health.

The first 1,000 days• Visual development

It is well established that the so-called ‘first 1,000 days’ – from the first day of pregnancy, until the age of two years – is critical for growth and development. Emerging evidence also suggests that early life nutrition is important in supporting visual health. While humans cannot synthesize lutein and zeaxanthin, maternal serum levels rise during pregnancy, with lutein being deposited in the fetal retina from the start of the second trimester.13

Early studies show that both lutein and zeaxanthin are present in prenatal eyes, at approximately 20 weeks’ gestation, and levels then decrease postpartum.14

substantial development. Lutein and zeaxanthin are deposited to generate MP as the foveal pit matures. This stage is fundamental for the foveal cone photoreceptors, which increase in density.15

In addition to being a pivotal stage in visual development, babies are also more susceptible to damaging blue light, as their

With peak concentrations in the fovea, the area of the eye that is responsible for sharp vision, macular pigment (MP) plays a critical role in maintaining the function of the macula (figure 4). Following birth, the fovea undergoes

Children and teenagers• Eye protection• Blue light exposure

There are an estimated 19 million children who are visually impaired worldwide. Of these, 12 million children are visually impaired due to refractive errors, a condition that could be easily diagnosed and corrected.17 Understandably, eye health is as much of a

Figure 4: Structure of the eye16

lenses are more transparent than adults. There are substantial levels of blue light in natural sunlight, as well as from artificial sources such as LED light bulbs and digital devices (figure 5).

It is therefore fundamental that steps are taken to ensure eye health is an important consideration, even as part of prenatal care.

concern for parents of children and teenagers, as it is for themselves as adults. According to a global DSM survey, 64% of parents worry about their children’s eye health.18

Given the risk of heightened blue light exposure via digital devices for children and teenagers, it is essential that steps are taken to look after the eyes of this age group. This is

Children and teenagers spend more time indoors than previous generations, and an increasingly large proportion are now exposed to higher levels of blue light through digital devices than their parents were.20 For example, in the UK, 81% of 10-15 year olds with a mobile phone also use a second screen while they watch television.21

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particularly important as young eyes are still developing. Protecting children’s eyes from UV light, regular examinations and a reduction in screen time can be beneficial. In addition, there is evidence that a balanced nutritious diet, such as the inclusion of oily fish, fruit, vegetables and nuts, can help improve eye health during childhood.19

Adults• Eye comfort • Visual improvement • Blue light exposure

For the adult age group, it is critical to maintain visual performance and proof against potential visual impairment in the future. Given the prevalence of underlying conditions that can lead to poor visual health, such as diabetes and high blood pressure, it is important to consider systematic health problems as part of a long-term preventative approach to eye care. If lifestyle choices, like

diet, sleep, exercise and smoking, are addressed during this life stage, it can help to maintain optimum visual health with advancing years.

However, a large number of adults are now exposed to high levels of blue light, not only from normal sunlight, but also from TVs, computers, smart phones and tablets. The peak emission of light from electronic devices is about 470 nm, midway through the blue light range (400-500 nm) (figure 6). Significant studies have found that at this wavelength,

there can be adverse effects on eye health. Although children and the elderly absorb more blue light than adults, their prolonged exposure is an important consideration in determining the correct prevention and treatment. The use of screens over long periods of time can also have a negative impact on the comfort of eyes in adults. Staring at digital devices without regular screen breaks can cause a stinging or burning feeling as the eyes dry out.22

Figure 5: Increased exposure to blue light through sunlight (1) and through indoor LED lighting (2)23

White LED | Flourescent | Incandescent

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Top of atmosphere (Air mass: 0)Earth surface (Air mass: 1.5)

VISIBLE

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In addition to the damaging effects of blue light, adult eyes are also subjected to a number of conditions that can affect visual performance. Refractive errors can affect adults over the age of 35 years, and can contribute to blurred vision, eye strain and double vision. Adults may also experience problems with glare sensitivity outside, for

example when driving or exercising in sunlight. Changes in the lens can result in light entering the eye in a scattered way, rather than focused on the retina – creating glare.

Similarly, photostress recovery may affect adult eyes when driving, causing bright lights to ‘blind’ people for a short period of time. The inability to distinguish between

contrasting patterns also becomes more prominent with age, as reading in low light becomes more difficult. Contrast sensitivity is therefore an important measure of visual function and performance. Glare sensitivity, photostress recovery and contrast sensitivity are all exacerbated with AMD.25,26

Figure 6: Blue light range24

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Elderly• Eye disease prevention

Aging is a significant risk factor for visual health. While advances in treatment have meant that visual impairment is no longer an inevitable consequence of aging, it is crucial that preventative measures continue to be put in place. As the number of people aged over 50 years is increasing, it is likely that the number of cases of AMD and cataracts will also rise.27 In addition, with underlying cases of diabetes also growing, the number of older people with sight problems looks set to double in the next 25 years.28 Smoking is another key modifiable risk factor with AMD;

It is important that elderly people with visual impairment are identified, and the condition be prevented if possible, as it can severely impact all areas of life. For example, poor eye health can also lead to reduced mobility and social isolation, as well as problems with taking medicines correctly and having a higher risk of falls and subsequent hospitalization.31

one study found that smoking increased the incidence of AMD in the elderly population with a ratio of 5.03, compared to non-smokers.29

Blue light exposure continues to be a threat for the elderly population, too. With increasing age, there is more absorption through the cornea and lens, compared to younger eyes. By the age of 60 years, only 20% of blue light is transmitted to the retina, which could be detrimental to the lens.30 As such, a preventative approach, that includes reduced blue light exposure, should also be considered.

SOCIO-DEMOGRAPHIC TRENDS SIGNIFICANTLY IMPACT EYE HEALTH

THE COST OF VISUAL IMPAIRMENT IS LIKELY TO INCREASEA recent report estimated that the annual cost impact of managing the consequences of severe/late stage AMD in the European Union (EU) is expected to be €89.46 billion per year. This includes the direct costs of treating and managing the disease, as well as the indirect costs related to productivity loss. Altogether, this translates to an annual healthcare cost of a severe/late stage AMD-attributed case transition in the EU of €34,805 per transition.34

burden. Given the economic toll associated with visual impairment, healthcare practitioners (HCPs) should be encouraged to explore preventative strategies in maintaining eye health, such as nutritional intervention.

According to WHO, 80% of all visual impairment can be prevented or cured.35 80%

There has already been significant progress in visual health over the last 20 years, thanks to the decrease in visual impairment through infectious diseases. This can be attributed to socioeconomic development, concerted public health action, increased availability of eye care services and improved awareness from consumers about solutions to the problems relating to visual impairment.32

However, socioeconomic development has been disproportionate across the world, and many people living in developing countries are still affected by visual impairment. Indeed, low socioeconomic status has been found to be a key risk factor in the development of eye disease. One particular review concluded that higher income, higher educational status and non-manual occupational social class were inversely associated with prevalence of blindness and visual impairment.33

This expense, combined with the costs associated with the aging population, is likely to increase even further over the next decade.

While eye diseases, such as AMD, are now more manageable, treatment remains expensive. Although new treatments for geographic atrophy (the advanced form of AMD) appear promising, and the treatment for wet AMD is advancing, it will be a costly

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A major challenge in supporting eye health is finding a solution that can meet the needs of a range of risk factors across different life stages. There is substantial evidence that a long-term preventative model could help to improve visual development and maintain eye health. As such, nutritional intervention presents a viable option, particularly given extensive research on the topic for all age groups.

Although there is a bank of evidence

EVIDENCE AND MECHANISM: A LONG-TERM PREVENTATIVE MODEL THAT WORKS

supporting the role of nutrition in eye health, the uptake of a balanced, nutritious diet is still limited worldwide. This is particularly prominent in low income countries, where visual impairment is prevalent. Currently, 90% of the world’s visually impaired live in low income settings.36 Fortified food and beverage products and dietary supplements could help to fill the gap, in particular when delivering the following essential nutrients.

Lutein and zeaxanthinA significant bank of evidence supports lutein and zeaxanthin for their role in eye health across all life stages. Both nutrients accumulate selectively in the fovea to form the MP. The MP is crucial in maintaining eye health, as it acts as a blue light filter and antioxidant, supporting the development of the fovea in early life, maintaining visual performance throughout adulthood and reducing the risk of AMD in later life.

fed a formula with low levels of these carotenoids. The results found that macular pigment optical density (MPOD) increased twice as much in breastfed infants, as those fed with low levels of carotenoids – with an intermediate increase with the formula supplemented with lutein, zeaxanthin, beta-carotene and lycopene. However, further studies are needed to determine whether formula supplementation that raises carotenoid tissue levels to match those in breastfed infants, would also match their foveal development.38

In addition, research has demonstrated improved visual performance in adults with lutein intake. A recent meta-analysis, conducted on the data from seven separate clinical studies, has found that lutein supplementation increased MPOD values, while also improving visual acuity and contrast sensitivity in AMD subjects.39 Not only this, taking lutein and zeaxanthin

together was found to decrease photostress recovery time, as well as increase chromatic contrast. There were also benefits of increased tolerance to glaring light.40

LuteinLutein has shown to have beneficial effects during pregnancy, playing an important role in early life nutrition. Together with zeaxanthin, lutein may decrease the severity of retinopathy of prematurity (ROP) in preterm infants. ROP, as well as diabetic retinopathy (DR), are leading causes of blindness in children and working-age adults respectively. Studies have highlighted lutein’s anti-inflammatory properties in neonatal eyes, suggesting that lutein supplementation could have a preventative role in disease initiation.37

Another study looked at the role of carotenoids in the developing macula, to investigate the importance of fortified infant formula. The in-vivo trial examined non-human primate infants for all aspects of foveal development, a significant postnatal change in eye health. Carried out from birth to six months, rhesus macaques were either breastfed, fed a formula supplemented with lutein, zeaxanthin, beta-carotene and lycopene, or

Lutein is considered as one of the main nutrients in the prevention of AMD. Although further research is still needed to assess the complete mechanism behind this indication, it is understood that the potent anti-inflammatory properties of lutein are a key factor in preventing the disease.

Already, studies have found that lutein functions as a blue light filter in the central retina, targeting reactive oxygen radicals. These findings, together with the fact that AMD patients’ blood contains higher levels of inflammation biomarkers, have led to a number of clinical trials in this area.

A study, presented at the International Carotenoids Symposium (ICS) 2017, carried out a double-blind placebo controlled intervention trial with lutein, following a set of inflammation biomarkers in the blood. The results found that there was a significant decrease in inflammatory activity in the macula in the subjects who were administered a 10mg dose of lutein per day. The placebo group in the study found no changes. This suggests that maintaining adequate levels of lutein could help to control the inflammatory pathway of the innate immune system in patients with AMD.41

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There is substantial evidence to suggest that zeaxanthin, together with lutein, can help in glare reduction and photostress recovery.

As people age, there is commonly a decrease in scotopic and shortwave sensitivity, affecting visual acuity. However, high levels of MP appear to have a beneficial effect on preserving scotopic and shortwave function. Given that lutein and zeaxanthin are already known to make up the MP, further studies have been carried out to assess the links between supplementation and a reduction in glare and improvement in photostress recovery. A double-blind, placebo-controlled study examined the visual effects of 10 mg/d lutein and 2 mg/d zeaxanthin in 115 young, healthy subjects over the course of a year. It was found that MPOD significantly increased with supplementation, compared to the placebo. Not only this, chromatic contrast and photostress time also increased, in line with results from previous studies.43

ZeaxanthinSimilar to lutein, zeaxanthin must be obtained from dietary sources and acts as a protective antioxidant in the eye. Several studies have highlighted how the carotenoid undergoes oxidation to protect the macula, helping to reduce the amount of stress-induced damage.42

AREDS and AREDS2: breakthroughs in nutritional supplement researchThe first age-related disease study (AREDS) in 2001 reported that a formulation of vitamin C, vitamin E, beta-carotene, zinc and copper could reduce the risk of developing AMD.44 Following this recommendation, the same research group began a second study in 2006, to further aid the AREDS formulation. AREDS2 tested:

• Adding antioxidants lutein and zeaxanthin

• Removing beta-carotene

• Lowering the dose of zinc

AREDS2 is, to date, the largest human study on nutritional supplements in eye health, and continues to inform subsequent research in the area.45

While the original AREDS study helped to form the basis for the second, there was no commercially available lutein or zeaxanthin at the time of the research in 2001.46

Designed by the National Eye Institute (NEI), AREDS2 examined patients with

existing AMD over a five-year period. Subjects were given 10 mg of lutein (FloraGLO® Lutein) and 2 mg of zeaxanthin (OPTISHARP®). The results found that there was a significant 18% reduction in the risk of progression to advanced AMD.

The AREDS2 study not only showed the benefits of lutein and zeaxanthin in the prevention of AMD, but also in reducing the progression of cataracts. Another ocular condition, cataracts reduce visual quality by clouding the lens. It remains a serious problem around the world; by 2050 the number of people in the US living with cataracts is predicted to rise to 50 million.47

According to the AREDS2 study, patients supplemented with the highest intake of lutein and zeaxanthin showed a significant reduction in risk of progression to cataract surgery (32% risk reduction), of any cataract (30% risk reduction) or of any severe cataract (36% risk reduction).48

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Health claims in the EUThere are a number of authorized health claims in the EU that substantiate the scientific evidence for nutrients in eye health, including the following:57

Normal health population (Article 13.1)

• DHA contributes to the maintenance of normal vision

• Riboflavin contributes to the maintenance of normal vision

• Vitamin A contributes to the maintenance of normal vision

• Zinc contributes to the maintenance of normal vision

Maternal intake (Article 14)

• DHA maternal intake contributes to the normal development of the eye of the fetus and breastfed infants

Infants (Article 14)

• DHA intake contributes to the normal visual development of infants up to 12 months of age

One study found that participants who reported the highest omega-3 long-chain polyunsaturated fatty acid intake were 30% less likely than their peers to develop central geographic atrophy and neovascular AMD.49

Omega-3s EPA and DHAThere is emerging evidence that suggests omega-3 fatty acids may help protect adult eyes from AMD, as well as dry eye syndrome. Eicosapentaenoic acid (EPA) and

Vitamin C, E and beta-caroteneThere is already far-reaching evidence that suggests vitamins C and E, as well as beta-carotene, can support human health. Further to this, there has also been research to determine their effects on eye health. The REACT (Roche European Anti-Cataract Trial) study evaluated whether daily supplementation of an antioxidant micronutrient combination can delay, stop or reverse the progression of early AMD. Following a period of three years, the results demonstrated a significant reduction in the cataract progression rate in the supplemented study population.51 Although more research in this area is required, the potential of vitamins C, E and beta-carotene appear promising, as part of a wider nutritional diet (figure 7).

ZincEmerging evidence links zinc intake with improved eye health. The mineral plays a role in the metabolic function of several important enzymes in the chorioretinal complex, helping to form a protective pigment in eyes.53 Zinc is highly concentrated in the eye, primarily in the retina and choroid, the vascular tissue

docosahexaenoic acid (DHA), in particular, have been noted for their effect on processes implicated in vascular and neural retinal pathogenesis.

Dry eye syndrome is another common, complex condition that reduces ocular comfort and visual performance – particularly in those aged 65 years and above. It is estimated that 3.23 million North Americans currently suffer from dry eyes, which can impact their quality of life.50 One report

Figure 7: The effect of vitamin C and E supplementation after three years, showing a significant reduction in cataract progression rate52

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layer under the retina. However, zinc levels in the eye have been found to decline with age.

Initial trials found that 200 mg per day of zinc sulfate over two years reduced the loss of vision in patients with AMD.54 Further to this, the original AREDS study concluded that intake of antioxidants in combination with

high-dose zinc or intake of high-dose zinc taken alone both significantly reduced the risk of AMD compared to the placebo group.55

Despite these promising figures, results have been generally inconsistent, and require further large, well-conducted randomized trials in other populations.56

carried out a meta-analysis to compare omega-3 fatty acid and placebo fatty acid in the management of dry eyes, and found that omega-3s could offer an effective therapy. Looking at seven independent studies, with a total of 790 participants, the results suggest omega-3s could be introduced to individuals’ diets in the prevention of both AMD and dry eye syndrome.

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An early influential study in 1994 found that intake of lutein and zeaxanthin through dark green leafy vegetables was strongly associated with a decreased risk of AMD.59

This led to the observation that both carotenoids are typically found together in nature, and present in a variety of fruits and vegetables, particularly corn, spinach, broccoli and kale. However, as the unesterified form of lutein is more readily absorbed in the body, it can be difficult to achieve adequate intake of both carotenoids by only eating vegetables, in which lutein and zeaxanthin are mainly present in their esterified form. This is also compounded by a relatively low consumption of fruit and vegetables worldwide.60

Given that the average intake of dietary lutein is likely to be far less (a typical US diet contains 1-3 mg/day of lutein and zeaxanthin) than the amounts associated with AMD risk reduction, supplementation may be a more efficient way of increasing lutein and zeaxanthin intake (figure 8).61 However, the question of compliance remains.

PRACTICAL SOLUTIONS FOR EYE HEALTH: AN OPPORTUNITY FOR LUTEIN AND ZEAXANTHIN

Figure 8: Average daily lutein and zeaxanthin consumption across the world58

USAEUROPECHINAJAPANBRAZIL

0.8–1.1 mg /day0.5–4 mg /day2.9 mg /day0.35 mg /day0.6–1.1 mg /day

A breakthrough study helped to confirm initial findings that indicated increased levels of carotenoids may reduce the risk of developing AMD. The results found that consuming 6 mg of lutein and zeaxanthin on average from their diet had a 57% reduction in risk of developing AMD, compared to those on an intake of 0.6 mg of lutein and zeaxanthin.62 These findings

led the way in the commercial production of carotenoid supplementation in supporting eye health, particularly given the potential cost savings in both the EU and US.63,64 Following a substantial bank of evidence, lutein and zeaxanthin are also widely used in infant formula.

Both AREDS and AREDS2 continue to inform patient eye health. Following a comparison of ocular nutritional supplements and the guidelines set by both studies, it was found that the majority of top-selling supplements did not contain identical ingredient dosages of AREDS and AREDS2. It has also been claimed that most product descriptions lacked sufficient scientific evidence, highlighting the importance of ophthalmologists in patient education on the evidence-based role of nutritional supplements in eye healthcare.65 As such, there is an opportunity for lutein and zeaxanthin, as well as other essential nutrients, to play a key role in eye health, with the help of further research.

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COST-EFFECTIVE AND FORESEEABLE PUBLIC HEALTH STRATEGIESIn addition to the potential for improving eye health across the life span, it has also been suggested that lutein and zeaxanthin supplementation could help to make significant cost savings for public health authorities worldwide.

supplementation of 10 mg lutein and 2 mg zeaxanthin to US adults (figure 9).67 These findings, based on the AREDS2 study, could help to make significant public health savings. Since only 4% of American adults over 55 years regularly supplement with lutein, there is an opportunity to include in future healthcare plans.68

Furthermore, a new paper published in the European Journal of Nutrition has stated that

establishing a recommended dietary reference intake (DRI) value for lutein is ‘critically important’ for advancing and improving public health. Based on the substantial bank of evidence that supports lutein’s role in eye health, the authors conclude that the carotenoid should be grouped together with other nutrients that hold DRI recommendations – particularly for those looking to optimize visual performance and reduce the risk of AMD.69

According to one report, an average spending of €6.20 billion per year is avoidable in the EU alone for over 50s with the use of lutein and zeaxanthin dietary supplements at protective levels. This is based on research to suggest lutein and zeaxanthin could yield less mild-to-severe/late stage AMD case transitions, compared to the placebo group.66

Figure 9: The amount of broccoli that would need to be consumed to achieve the recommended daily intake of lutein and zeaxanthin70

1–2mg lutein & zeaxanthin

10mg lutein &2mg zeaxanthin

Although the EU currently does not have an EFSA-recognized recommended daily intake level for lutein and zeaxanthin, the American Optometric Association (AOA) recommends a

CONCLUSION: THE IMPORTANCE OF NUTRIENTS FOR IMPROVING FUTURE EYE HEALTH Widespread concerns about eye health have allowed for a bank of scientific evidence to be built on the mechanisms that lead to visual impairment. Given the impact that eye diseases, such as AMD, have on individuals’ lives, it is important that these studies are thoroughly considered in order to improve public health strategies across the world. This should be a priority, not only in developing countries where visual impairment is prevalent, but also in countries where better eye care would increase comfort and quality of life.

There is compelling evidence to suggest that micronutrients, including lutein, zeaxanthin, omega-3s EPA and DHA, vitamins C, E and beta-

carotene, as well as zinc, can support eye health across all life stages. It would therefore be worthwhile to consider the role of nutrition and a healthy diet in preventing visual impairment. This, together with increased visual examinations, could form a cost-effective multi-faceted approach through both prevention and detection.

Studies in this area have highlighted scientific breakthroughs that could have a serious impact on eye health in the future. However, further research is needed on the use of micronutrients, to ensure that the number of people worldwide with visual impairment continues to decrease.

• Eye health is a key health concern that affects individuals across all life stages.

• Healthcare and the related costs of managing poor eye health look set to rise even further in the future, due to an aging population.

• As well as the financial toll, the social implications of visual impairment have serious repercussions on everyday life.

• There is substantial evidence to suggest that carotenoids,

such as a lutein and zeaxanthin, omega-3s EPA and DHA, and vitamins C, E, beta-carotene and zinc, may have a beneficial role in supporting eye health.

• A long-term preventative approach should be considered, which focuses on specific age ranges and risk factors.

• Studies highlight how improved nutrition – either through a fortified diet or supplementation – could help with visual development, protection, performance and eye comfort.

Key take-away messages

References1. WHO, 'Global data on visual impairments 2010', 2010 [report].

2. J. Seddon et al., ‘The US twin study of age-related macular degeneration; relative roles of genetic and environmental influences’, Arch Ophthalmol, vol. 123, 2005, p. 321-327.

3. WHO, ‘Visual impairment and blindness’, [website], 2017, http://www.who.int/mediacentre/factsheets/fs282/en/, (accessed 18 October 2017).

4. Op. cit. (WHO, 2010).

5. National Eye Institute, ‘Age-related macular degeneration (AMD)’, [website], https://nei.nih.gov/health/maculardegen, (accessed 6 October 2017).

6. American Foundation for the Blind, ‘Vision aware: the difference between wet and dry age-related macular degeneration’, [website], http://www.visionaware.org/info/your-eye-condition/age-related-macular-degeneration-amd/wet-and-dry-amd/125, (accessed 20 October 2017).

7. K. Gehrs et al., ‘Age-related macular degeneration – emerging pathogenetic and therapeutic concepts’, Ann Med, vol. 38, no. 7, 2006, p. 450-471.

8. A. Kijlstra et al., ‘Lutein: More than just a filter for blue light.’, Prog Retin Eye Res, vol. 31, no. 4, 2012, p. 303-315.

9. DSM, ‘Global health concerns’, 2017 [report].

10. Op. cit. (WHO, 2017).

11. Ibid.

12. Ibid.

13. J.P. Zimmer et al., ‘Possible influences of lutein and zeaxanthin on the developing retina’, Clin Ophthalmol, vol. 1, no. 1, 2007, p. 25-35.

14. M. Zielinska et al., ‘Health effects of carotenoids during pregnancy and lactation’, Nutrients, vol. 9, no. 8, 2017, p. 838.

15. T. McGill et al., ‘Elevated Fundus Autofluorescience in Monkeys Deficient in Lutein, Zeaxanthin, and Omega-3 Fatty Acids’, Invest Ophthalmol Vis Sci, vol. 57, no. 3, 2016, p. 1361-1369.

16. DSM, ‘Upgrade your vision’, 2016 [video], https://www.youtube.com/watch?v=vYv5mwHGuBg&t=1s (accessed 13 December 2017).

17. Op. cit. (WHO, 2017).

18. Op. cit. (DSM, 2017).

19. American Optometric Association, ‘Diet and nutrition’, [website], https://www.aoa.org/patients-and-public/caring-for-your-vision/diet-and-nutrition, (accessed 17 October 2017).

20. Natural England, ‘Monitor of engagement with the Natural Environment pilot study: visits to the natural environment by children’, [report], 2016.

21. DSM, ‘Blue light in the digital age’, [website], https://www.dsm.com/markets/personal-care/en_US/insights/our-concepts/beat-the-blues/blue-light-in-the-digital-age.html, (accessed 18 October 2017).

22. National Eye Institute, ‘Facts about dry eye’, [website], 2017, https://nei.nih.gov/health/dryeye/dryeye, (accessed 12 October 2017).

23. Op. cit. (DSM, 2016).

24. DSM Nutritional Products and Kemin Industries Inc., ‘Vision and Blue Light’, [website], https://www.kemin.com/en/north-america/products/floraglo-lutein/beat-the-blue, (accessed 20 December 2017).

25. J.M. Stringham et al., ‘Macular carotenoid supplementation improves disability glare performance and dynamics of photostress recovery’, Eye Vis (Lond.), vol. 3, no. 30, 2016.

26. B.R. Hammond et al., ‘A double-blind, placebo-controlled study on the effects of lutein and zeaxanthin on photostress recovery, glare disability, and chromatic contrast’, Invest Ophthalmol Vis Sci, vol. 55, 2014, p. 8583-8589.

27. J. Evans, ‘Eye care for older people’, Community Eye Health, vol. 21, no. 66, 2008.

28. B. McLaughlan, ‘Open your eyes – a three point action plan to address the UK’s impending eye health crisis’, RNIB, 2005 [report].

29. S. Rasoulinejad et al., ‘Prevalence of age-related macular degeneration among the elderly’, Caspian J Intern Med, vol. 6, no. 3, 2015, p. 141-7.

30. J. Dillon et al., ‘Transmission of light to the aging human retina: possible implications for age related macular degeneration’, Exp Eye Res, vol. 79, no. 6, 2004, p. 753-9.

31. Royal National Institute of Blind People (RNIB), ‘Older people and eye tests: don’t let age rob you of your sight’, 2007 [report].

32. Op. cit. (WHO, 2017).

33. S. Leamon et al., ‘Improving access to optometry services for people at risk of preventable sight loss: a qualitive study in five UK locations’, J Public Health (Oxf), vol. 36, no. 4, 2014, p. 667-673.

34. C. Shanahan, ‘The economic benefits of using lutein and zeaxanthin food supplements in the European Union’, Frost & Sullivan, 2017 [report].

35. Op. cit. (WHO, 2017).

36. Ibid.

37. X. Gong and L. Rubin, ‘Role of macular xanthophylls in prevention of common neovscaular retinopathies: retinopathy of prematurity and diabetic retinopathy’, Archives of Biochemistry and Biophysics, vol. 572, 2015, p. 40-48.

38. Op. cit. (T. McGill et al.).

39. G. Weigert et al., ‘Effects of lutein supplementation on macular pigment optical density and visual acuity in patients with age-related macular degeneration’, Invest Ophthalmol Vis Sci, vol. 52, no. 11, 2011, p. 8174-8178.

40. Op. cit. (B.R. Hammond et al.).

41. Op. cit. (A. Kijlstra et al.).

42. P. Bernstein et al., ‘Lutein, zeaxanthin and meso-zeaxanthin: the basic and clinical science underlying carotenoid-based nutritional interventions against ocular disease’, Prog Retin Eye Res, vol. 50, 2016, p. 34-66.

43. Op. cit. (B.R. Hammond et al.).

44. Age-related eye disease study research group, ‘A randomized, placebo-controlled, clinical trial of high dose supplementation with vitamins C and E, beta-carotene and zinc for age-related macular degeneration and vision loss (AREDS), Arch Ophthalmol, vol. 119, no. 10, 2001, p. 1417-1436.

45. E. Chew et al., ‘The age-related disease study 2 (AREDS2): study design and baseline characteristics AREDS2 report number 1’, Ophthalmology, vol. 119, no. 11, 2012, p. 2282-2289.

46. Ibid.

47. NEI, ‘Cataracts’ [website], https://nei.nih.gov/health/cataract, (accessed 6 October 2017).

48. Op. cit. (E. Chew et al.).

49. J. Sangiovanni et al., ‘Omega-3 long-chain polyunsaturated fatty acid intake and 12-y incidence of neovascular age-related macular degeneration and central gepgraphic atrophy: AREDS report 30, a prospective cohort study from the age-related eye disease study’, Am J Clin Nutr, vol. 90, no. 6, 2009, p. 1601-7.

50. A. Liu and J. Ji, ‘Omega-3 essential fatty acids therapy for dry eye syndrome: a meta-analysis of randomized controlled studies’, Med Sci Monit, vol. 20, no. 6, 2014, p. 1583-9.

51. L. Chylack et al., ‘The Roche European American Cataract Trial (REACT): a randomized clinical trial to investigate the efficacy of an oral antioxidant micronutrient mixture to slow progression of age-related cataract’, Ophthalmic Epidemiol, vol. 9, no. 1, 2002, p. 49-80.

52. Ibid.

53. D. Newsome, ‘Oral zinc in macular degeneration’, Arch Ophthalmol, vol. 106, no. 2, 1988, p. 192-8.

54. Ibid.

55. Op. cit. (Age-related eye disease study research group, 2001).

56. J. Evans, ‘Antioxidant vitamin and mineral supplements for slowing the progression of age-related macular degeneration’, Cochrane Database Syst Rev, vol. 19, no. 2, 2006.

57. EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA), ‘Scientific Opinion on the substantiation of health claims related to docosahexaenoic acid (DHA) and maintenance of normal (fasting) blood concentrations of triglycerides (ID 533, 691, 3150), protection of blood lipids from oxidative damage (ID 630), contribution to the maintenance or achievement of a normal body weight (ID 629), brain, eye and nerve development (ID 627, 689, 704, 742, 3148, 3151), maintenance of normal brain function (ID 565, 626, 631, 689, 690, 704, 742, 3148, 3151), maintenance of normal vision (ID 627, 632, 743, 3149) and maintenance of normal spermatozoa motility (ID 628) pursuant to Article 13(1) of Regulation (EC) No 1924/2006,’ EFSA Journal, vol. 8, no. 10, 2010, p. 1734.

58. Kemin, ‘FloraGlo® by Kemin: The Pioneers of Lutein Science and Discovery’, 2016 [report].

59. J. Seddon et al., ‘Dietary carotenoids, vitamins A, C and E, and advanced age-related macular degeneration. Eye disease case-control study group’, JAMA, vol. 272, no. 18, 1994, p. 1413-20.

60. WHO, ‘Promoting fruit and vegetable consumption around the world’ [website], http://www.who.int/dietphysicalactivity/fruit/en, (accessed 6 October 2017).

61. E. Abdel-Aal et al., ‘Dietary sources of lutein and zeaxanthin carotenoids and their role in eye health’, Nutrients, vol. 5, no. 4, 2013, p. 1169-1185.

62. Op. cit. ( J. Seddon et al.).

63. Op. cit. (C. Shanahan et al., 2017).

64. C. Shanahan, ‘Smart prevention – health care cost savings resulting from the targeted use of dietary supplements’, Frost & Sullivan, 2013 [report].

65. J. Yong et al., ‘Ocular nutritional supplements’, Ophthalmology, vol. 122, no. 3, 2015, p. 595-599.

66. Op. cit. (C. Shanahan et al., 2017).

67. Ibid.

68. Op. cit. (C. Shanahan et al., 2013).

69. K. Ranard et al., ‘Dietary guidance for lutein: consideration for intake recommendations is scientifically supported’, European Journal of Nutrition, 2017.

70. DSM Nutritional Products and Kemin Industries Inc., ‘Vision and Blue Light’, [website], https://www.kemin.com/en/north-america/products/floraglo-lutein/beat-the-blue, (accessed 20 December 2017).

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