Recently one of my clients was diagnosed with age-related macular degeneration and was advised by a health professional to take supplements of the carotenoids lutein and zeaxanthin to prevent progression of this condition. Given that these supplements are expensive, she wanted to know if her investment would pay off.
As discussed below, the bottom line is that, to date, there is little scientific evidence to support the use of antioxidant supplements either to prevent or delay the progression of age-related macular degeneration. Indeed, there is evidence that such supplements may be harmful.
In contrast, there is scientific evidence that consumption of a plant-based diet with a variety of whole grains, vegetables and fruit has many benefits with regard to preventing and treating diseases like macular degeneration, and does no harm. Further research is required in this area.
The best way to protect the health of your eyes is to eat plenty of different coloured vegetables and fruit; for example, broccoli, cabbage, kale, collard greens, green peas, spinach, courgettes, red and yellow peppers, winter squash, kiwi fruit, blueberries, oranges and mango.
What is age-related macular degeneration?
Age-related macular degeneration is an eye condition affecting older people, and involves the loss of the person’s central field of vision. It occurs when the macular (or central) retina in the eye develops degenerative lesions. The retina is the light-detecting membrane at the back of the eye. The macula contains a particularly high density of light receptors, especially cones (the receptors that detect colour) and so the macula is particularly important for seeing fine detail and objects directly in front of us. It plays a vital role in helping people to read, write, drive and perform other detailed tasks. It also enables us to recognise faces and see colour.
According to the World Health Organisation (1), globally, age-related macular degeneration ranks third as a cause of blindness after cataract and glaucoma; it is the primary cause in industrialized countries. Several forms of age-related macular degeneration exist.
Carotenoid pigments in the eye – lutein, zeaxanthin and meso-zeaxanthin
Pigments known as carotenoids are found within the eye. There are over 600 known carotenoids in nature but in the human eye, just three of these pigments – lutein, zeaxanthin and meso-zeaxanthin – form a concentrated ‘yellow spot’ in the macula, known as the macular pigment. This pigment has two main functions: it acts as an antioxidant and it filters light.
As short wavelength (blue) light passes through the retina to the photoreceptors and pigmented epithelial cells, reactive oxygen species are generated. The conversion of the light energy into a nerve impulse by the photoreceptors generates free radicals – unstable molecules which damage a variety of tissues – resulting in many of the diseases and conditions associated with ageing. Antioxidants in the eye are able to quench these free radicals, thereby protecting the eye from oxidative damage. Lutein, zeaxanthin and particularly meso- zeaxanthin are very effective antioxidants.
The pigments lutein and zeaxanthin can be found naturally in a number of food sources (2). For example, lutein can be found in yellow peppers, mango, bilberries and green leafy vegetables such as kale, spinach, chard and broccoli. Zeaxanthin can be found in winter squash, orange sweet peppers, broccoli, corn, lettuce, spinach, tangerines, oranges and eggs.
Blue light, because of its relatively high photon energy, more readily damages the retina than yellow or red light, which is less energetic. The macular pigment acts as a filter, particularly to blue light, and therefore protects against this damaging effect.
Given that the development of age-related macular degeneration is likely to involve a complex interaction of cellular and vascular factors, which may be promoted by light damage, oxidative stress, and inflammation, it is biologically plausible that a number of dietary components may be protective.
Effect of diet on age-related macular degeneration
The results of several epidemiological studies and clinical trials in the peer-reviewed scientific literature suggest that diets high in antioxidant nutrients (vitamins C and E, carotenoids such as lutein and zeaxanthin, fruit and vegetables that contain these nutrients, and non-nutritive antioxidants) or zinc are associated with a decreased occurrence of early or late age-related macular degeneration (3) (4). A high dietary intake of fat was associated with a higher prevalence or incidence of early or late age-related macular degeneration in numerous studies (5), whereas higher intakes of fish or omega 3 fatty acids were associated with lower rates of age-related macular degeneration (5).
Despite nutritional advice being available, awareness of the link between diet and eye health is poor. A survey conducted by the Eyecare Trust (6) found that Britons are oblivious to the fact that unhealthy lifestyles and obesity can substantially increase the risk of macular degeneration and ultimately blindness.
Efficacy of nutrient supplements for age-related macular degeneration
Some clinicians argue that it is difficult to obtain adequate amounts of the protective nutrients required for the eyes from a ‘normal’ diet. They thus prescribe high doses of nutrient supplements. But are these nutritional supplements effective?
A recently published Cochrane Review (7) identified four large, high-quality randomised controlled trials which included 62,520 people. The trials were conducted in Australia, Finland and the USA and investigated the effects of vitamin E and beta-carotene supplementation. These trials provide evidence that taking vitamin E and beta-carotene supplements is unlikely to prevent the onset of age-related macular degeneration. There was no evidence for other antioxidant supplements and commonly marketed combinations.
Another Cochrane Review (8) investigated whether progression of age-related macular degeneration may be slowed down in people who take antioxidant supplements (carotenoids, vitamins C and E) or minerals (selenium and zinc). The authors identified 13 randomised controlled trials which included 6150 participants; five trials based in the USA, two in the UK, two trials in Austria, and one trial in each of a further four countries (Australia, China, Italy and Switzerland). The review of trials found that supplementation with antioxidants and zinc may be of modest benefit in people with age-related macular degeneration. This was seen mainly in one large trial that followed up participants for an average of six years. The other smaller trials with shorter follow-up do not provide evidence of any benefit. Large well-conducted trials in a range of populations and with different nutritional status are required.
Safety of antioxidant nutrient supplements
Although generally regarded as safe, there is evidence that antioxidant supplements may have harmful effects. A Cochrane Review in 2008 (9) demonstrated that antioxidant supplements seem to increase mortality in sufferers of cancer and cardiovascular disease. This review was updated in 2012 (10) and found no evidence to support antioxidant supplements for primary or secondary prevention. Beta-carotene and vitamin E seem to increase mortality, and so may higher doses of vitamin A. The authors concluded that current evidence does not support the use of antioxidant supplements in the general population or in patients with various diseases in a stable phase, including gastrointestinal, cardiovascular, neurological, ocular, dermatological, rheumatoid, renal, endocrinological, or unspecified diseases.
Conclusion
The bottom line from all of this work is that, to date, there is little evidence to support the use of antioxidant supplements either to prevent or delay the progression of macular degeneration. Indeed, there is evidence that such supplements may be harmful.
In contrast, consumption of a plant-based diet with a variety of whole grains, vegetables and fruit has many benefits with regard to preventing and treating disease, and none of the disadvantages associated with nutritional supplements. Further research and analysis of the literature is required in this area.
Further information and help
If you are suffering from a specific health problem or would just like to improve your general health and well-being, you will benefit from a personal nutrition consultation. Simple changes to diet and lifestyle can lead to significant improvements in the way you feel. For a delicious recipe full of the carotenoids lutein and zeaxanthin, please click here.
References
(1) http://www.who.int/blindness/causes/priority/en/index8.html
(2) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1722697/
(3) http://www.ncbi.nlm.nih.gov/pubmed/16380590?dopt=Abstract
(4) http://informahealthcare.com/doi/abs/10.3109/09286580903450353
(5) http://www.ncbi.nlm.nih.gov/pubmed/14662593?dopt=Abstract
(6) http://www.eyecaretrust.org.uk/view.php?item_id=563
(7) http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000253.pub3/abstract
(8) http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000254.pub3/abstract
(9) http://www.ncbi.nlm.nih.gov/pubmed/18425980
(10) http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007176.pub2/abstract
Jane Philpott's Food, Nutrition and Cookery Blog 
Hi Jane, Thanks for highlighting this important age-onset disease. My maternal family is badly impacted by this and the hereditary aspect shouldn’t be forgotten. Its affected 3 generations in my family, one after the other and unfortunately diet hasn’t prevented it. My grandfather spent his adult life as a small holder growing and cooking fresh veg but lost his vision almost entirely in his 70s. His son has it as badly whereas my mum’s is under control. She does take expensive lutein supplements and has managed to prevent her eyesight deteriorating beyond night blindness. It seems crucial whether you have the wet or dry condition. My poor uncle has wet in one eye and dry in the other but is now registered blind. As you say eating such wide ranging veg will very much help. But unfortunately it helps some more than others