Macular pigment optical density and its relationship with serum and dietary levels of lutein and zeaxanthin

Macular pigment optical density measurements: evaluation of a device using heterochromatic flicker photometry

PURPOSE

Accurate assessment of the amount of macular pigment (MPOD) is necessary to investigate the role of carotenoids and their assumed protective functions. High repeatability and reliability are important to monitor patients in studies investigating the influence of diet and supplements on MPOD. We evaluated the Macuscope (Macuvision Europe Ltd., Lapworth, Solihull, UK), a recently introduced device for measuring MPOD using the technique of heterochromatic flicker photometry (HFP). We determined agreement with another HFP device (QuantifEye; MPS 9000 series: Tinsley Precision Instruments Ltd., Croydon, Essex, UK) and a fundus reflectance method.

METHODS

The right eyes of 23 healthy subjects (mean age 33.9 ± 15.1 years) were measured. We determined agreement with QuantifEye and correlation with a fundus reflectance method. Repeatability of QuantifEye was assessed in 20 other healthy subjects (mean age 32.1 ± 7.3 years). Repeatability was also compared with measurements by a fundus reflectance method in 10 subjects.

RESULTS

We found low agreement between test and retest measurements with Macuscope. The average difference and the limits of agreement were -0.041 ± 0.32. We found high agreement between test and retest measurements of QuantifEye (-0.02 ± 0.18) and the fundus reflectance method (-0.04 ± 0.18). MPOD data obtained by Macuscope and QuantifEye showed poor agreement: -0.017 ± 0.44. For Macuscope and the fundus reflectance method, the correlation coefficient was r = 0.05 (P = 0.83). A significant correlation of r = 0.87 (P<0.001) was found between QuantifEye and the fundus reflectance method.

CONCLUSIONS

Because repeatability of Macuscope measurements was low (ie, wide limits of agreement) and MPOD values correlated poorly with the fundus reflectance method, and agreed poorly with QuantifEye, the tested Macuscope protocol seems less suitable for studying MPOD.

Dietary supplementation: effects on visual performance and occurrence of AMD and cataracts

OBJECTIVE

To evaluate results of studies that have provided information regarding the effects of dietary supplementation on visual performance, development and progression of age-related macular degeneration (AMD), and risk for cataracts.

RESEARCH DESIGN AND METHODS

Studies with information about the effects of dietary supplementation were identified via PubMed searches that combined (in separate searches) the terms 'supplement' OR 'supplementation' OR 'diet' AND 'cataract' or 'macular degeneration' or 'visual' OR 'vision'. Additional references concerned with biologic effects of specific agents, measurement of visual function, and the etiology and epidemiology of cataracts and AMD were identified on the basis of PubMed conventional literature searches.

RESULTS

Studies of the effects of dietary supplementation, primarily with preparations including lutein and zeaxanthin, have demonstrated improvements in contrast sensitivity and visual performance under glare conditions that, in some studies, have been correlated with effects of treatment on macular pigment optical density. Results from both observational and prospective interventional studies generally support the conclusion that dietary supplements including these xanthophylls significantly decrease the occurrence of AMD and the development of nuclear lens opacities. However, there is variability in results regarding effects of dietary supplementation that may be related to limitations of long-term observational or interventional studies and which cannot be easily controlled or which may also be related in some studies to other important, yet unrecorded, diet- and lifestyle-related factors that are capable of influencing the risks for AMD and/or cataracts.

CONCLUSIONS

The multiple benefits of dietary supplementation support the development and use of these preparations to promote optimal visual function and decrease risk for AMD and cataracts. Increasing understanding of the optimal approach to supplementation will depend upon results from interventional studies that also carefully evaluate and analyze well-established factors for these two conditions.

Variability of Carotenoid Biosynthesis in Orange Colored Capsicum spp

Pepper, Capsicum spp., is a worldwide crop valued for heat, nutrition, and rich pigment content. Carotenoids, the largest group of plant pigments, function as antioxidants and as vitamin A precursors. The most abundant carotenoids in ripe pepper fruits are β-carotene, capsanthin, and capsorubin. In this study, the carotenoid composition of orange fruited Capsicum lines was defined along with the allelic variability of the biosynthetic enzymes. The carotenoid chemical profiles present in seven orange pepper varieties were determined using a novel UPLC method. The orange appearance of the fruit was due either to the accumulation of β-carotene, or in two cases, due to only the accumulation of red and yellow carotenoids. Four carotenoid biosynthetic genes, Psy, Lcyb, CrtZ-2, and Ccs were cloned and sequenced from these cultivars. This data tested the hypothesis that different alleles for specific carotenoid biosynthetic enzymes are associated with specific carotenoid profiles in orange peppers. While the coding regions within Psy and CrtZ-2 did not change in any of the lines, the genomic sequence contained introns not previously reported. Lcyb and Ccs contained no introns but did exhibit polymorphisms resulting in amino acid changes; a new Ccs variant was found. When selectively breeding for high provitamin A levels, phenotypic recurrent selection based on fruit color is not sufficient, carotenoid chemical composition should also be conducted. Based on these results, specific alleles are candidate molecular markers for selection of orange pepper lines with high β-carotene and therefore high pro-vitamin A levels.

Location of macular xanthophylls in the most vulnerable regions of photoreceptor outer-segment membranes

Lutein and zeaxanthin are two dietary carotenoids that compose the macular pigment of the primate retina. Another carotenoid, meso-zeaxanthin, is formed from lutein in the retina. A membrane location is one possible site where these dipolar, terminally dihydroxylated carotenoids, named macular xanthophylls, are accumulated in the nerve fibers and photoreceptor outer segments. Macular xanthophylls are oriented perpendicular to the membrane surface, which ensures their high solubility, stability, and significant effects on membrane properties. It was recently shown that they are selectively accumulated in membrane domains that contain unsaturated phospholipids, and thus are located in the most vulnerable regions of the membrane. This location is ideal if they are to act as lipid antioxidants, which is the most accepted mechanism through which lutein and zeaxanthin protect the retina from age-related macular degeneration. In this mini-review, we examine published data on carotenoid-membrane interactions and present our hypothesis that the specific orientation and location of macular xanthophylls maximize their protective action in membranes of the eye retina.

Macular pigment and its contribution to visual performance and experience

There is now a consensus, based on histological, biochemical and spectral absorption data, that the yellow colour observed at the macula lutea is a consequence of the selective accumulation of dietary xanthophylls in the central retina of the living eye. Scientific research continues to explore the function(s) of MP in the human retina, with two main hypotheses premised on its putative capacity to (1) protect the retina from (photo)-oxidative damage by means of its optical filtration and/or antioxidant properties, the so-called protective hypothesis and (2) influence the quality of visual performance by means of selective short wavelength light absorption prior to photoreceptor light capture, thereby attenuating the effects of chromatic aberration and light scatter, the so-called acuity and visibility hypotheses. The current epidemic of age-related macular degeneration has directed researchers to investigate the protective hypothesis of MP, while there has been a conspicuous lack of work designed to investigate the role of MP in visual performance. The aim of this review is to present and critically appraise the current literature germane to the contribution of MP, if any, to visual performance and experience.

The value of measurement of macular carotenoid pigment optical densities and distributions in age-related macular degeneration and other retinal disorders

There is increasing recognition that the optical and antioxidant properties of the xanthophyll carotenoids lutein and zeaxanthin play an important role in maintaining the health and function of the human macula. In this review article, we assess the value of non-invasive quantification of macular pigment levels and distributions to identify individuals potentially at risk for visual disability or catastrophic vision loss from age-related macular degeneration, and we consider the strengths and weaknesses of the diverse measurement methods currently available.

A new desktop instrument for measuring macular pigment optical density based on a novel technique for setting flicker thresholds

A rapid portable technique for estimating macular pigment optical density (MPOD) in large populations is described. The new instrument utilises a novel method for setting flicker thresholds which is undemanding for naïve and elderly observers and easily operated by a non-technical person. The method has good repeatability (r = 0.97) and the data are comparable with an optical method based on retinal reflectometry (r = 0.78). MPOD spatial profiles are presented for seven normal observers and these are well described (r = 0.99) by a decaying exponential function consistent with previous reports. MPOD values are presented from 5581 (2435 females and 3146 males) individuals measured in 48 optometric practices. The mean MPOD of this population was 0.33 (S.D. +/- 0.187) which is similar to previous large scale studies of MP.

Monthly Consistency of Macular Pigment Optical Density and Serum Concentrations of Lutein and Zeaxanthin

PURPOSE

This study was undertaken to assess serial month-to-month consistency of macular pigment (MP) optical density and serum concentrations of lutein (L) and zeaxanthin (Z). Four healthy subjects aged between 23 and 51 years volunteered to participate in this study.

METHODS

MP optical density (measured psychophysically using heterochromatic flicker photometry [HFP]), and serum concentrations of L and Z (quantified using high-performance liquid chromatography [HPLC]), were recorded every month for 24 consecutive months.

RESULTS

Mean MP optical density (+/-SD) was 0.361 (0.086) and 0.369 (0.074) for right and left eyes, respectively. There was no statistically significant seasonal variation in MP optical density for the group (two-way ANOVA: p>0.05). Serum concentrations of L and Z demonstrated a statistically significant subject-season interaction effect (two-way ANOVA: p<0.01). Serial serum concentrations of L and Z were positively correlated within all four subjects (r=0.370 to 0.786), and significantly so for three subjects (p<0.05). There was no obvious relationship, synchronous or lagged, between serum concentrations of L (or Z) and MP optical density (r=-0.036 to 0.368).

CONCLUSIONS

MP optical density was relatively stable for all subjects over the 24-month period. Fluctuations in serum concentrations of L and Z, in the absence of dietary modification or supplementation, are associated with stable MP optical density.

Lutein and zeaxanthin in eye and skin health

Less than 20 of the hundreds of carotenoids found in nature are found in the human body. These carotenoids are present in the body from the foods or dietary supplements that humans consume. The body does not synthesize them. Among the carotenoids present in the body, only lutein and its coexistent isomer, zeaxanthin, are found in that portion of the eye where light is focused by the lens, namely, the macula lutea. Numerous studies have shown that lutein and zeaxanthin may provide significant protection against the potential damage caused by light striking this portion of the retina. In the eye, lutein and zeaxanthin have been shown to filter high-energy wavelengths of visible light and act as antioxidants to protect against the formation of reactive oxygen species and subsequent free radicals. Human studies have demonstrated that lutein and zeaxanthin are present in the skin, and animal studies have provided evidence of significant efficacy against light-induced skin damage, especially the ultraviolet wavelengths. Little was known about the protective effects of these carotenoids in human skin until recently. This article reviews the scientific literature pertaining to the effects that lutein and zeaxanthin exhibit in the human eye and skin.

Prospective study of lutein/zeaxanthin intake and risk of age-related macular degeneration

BACKGROUND

The association between lutein/zeaxanthin intake and age-related macular degeneration (AMD) risk may differ by smoking status, vitamin C and E intakes, and body fatness.

OBJECTIVE

The objective was to evaluate the association between lutein/zeaxanthin intake and AMD risk by smoking status, intake of antioxidant vitamins, and body fatness.

DESIGN

We conducted a prospective follow-up study of 71 494 women and 41 564 men aged >or=50 y and had no diagnosis of AMD or cancer. Diet was assessed with a validated semiquantitative food-frequency questionnaire.

RESULTS

During up to 18 y of follow-up, we documented 673 incident cases of early AMD and 442 incident cases of neovascular AMD with a visual loss of 20/30 or worse due primarily to AMD. Lutein/zeaxanthin intake was not associated with the risk of self-reported early AMD. There was a statistically nonsignificant and nonlinear inverse association between lutein/zeaxanthin intake and neovascular AMD risk; the pooled multivariate relative risks for increasing quintiles of intake were 1.00 (referent), 0.80, 0.84, 0.97, and 0.72 (95% CI: 0.53, 0.99) (P for trend = 0.14). For early AMD, the association with lutein/zeaxanthin intake did not vary by smoking status, intakes of vitamins C and E, or body mass index. For neovascular AMD, a nonlinear inverse association was found among never smokers.

CONCLUSIONS

These data do not support a protective role of lutein/zeaxanthin intake on risk of self-reported early AMD. The suggestion of inverse associations related to the risk of neovascular AMD needs to be examined further.

Toxicity profile of lutein and lutein ester isolated from marigold flowers (Tagetes erecta)

Lutein is a carotenoid with antioxidant properties and is commonly present in many fruits, vegetables, and egg yolk. Lutein affords protection against the development of the two common eye diseases of aging: cataract and macular degeneration. As the dietary lutein concentration is much lower compared to the actual requirement to reduce macular degeneration, supplementation of lutein is under consideration. There are very few data on the toxicity of lutein. In the present study, the authors have evaluated the short-term and long-term toxicity profile of lutein and its esterified form isolated from marigold flowers (Tagetes erecta) in young adult male and female Wistar rats. Lutein and its ester form administered orally at doses of 4, 40, and 400 mg/kg body weight for 4 weeks for short-term toxicity study and 13 weeks for a subchronic toxicity study did not produced any mortality, change in body weight, food consumption pattern, organ weight, and other adverse side reactions. Administration of lutein and ester form did not alter the hepatic and renal function, and did not produce any change in the hematological parameters and in lipid profile. Histopathological analysis of the organs supported the nontoxicity of lutein and its ester form.

Macular pigment and lutein supplementation in ABCA4-associated retinal degenerations

PURPOSE

To determine macular pigment (MP) optical density (OD) in patients with ABCA4-associated retinal degenerations (ABCA4-RD) and the response of MP and vision to supplementation with lutein.

METHODS

Patients with Stargardt disease or cone-rod dystrophy and known or suspected disease-causing mutations in the ABCA4 gene were included. All patients had foveal fixation. MPOD profiles were measured with heterochromatic flicker photometry. Serum carotenoids, visual acuity, foveal sensitivity, and retinal thickness were quantified. Changes in MPOD and central vision were determined in a subset of patients receiving oral supplementation with lutein for 6 months.

RESULTS

MPOD in patients ranged from normal to markedly abnormal. As a group, patients with ABCA4-RD had reduced foveal MPOD, and there was a strong correlation with retinal thickness. Average foveal tissue concentration of MP, estimated by dividing MPOD by retinal thickness, was normal in patients, whereas serum concentration of lutein and zeaxanthin was significantly lower than normal. After oral lutein supplementation for 6 months, 91% of the patients showed significant increases in serum lutein, and 63% of the patients' eyes showed a significant augmentation in MPOD. The retinal responders tended to be female and to have lower serum lutein and zeaxanthin, lower MPOD, and greater retinal thickness at baseline. Responding eyes had significantly lower baseline MP concentration than did nonresponding eyes. Central vision was unchanged after the period of supplementation.

CONCLUSIONS

MP is strongly affected by the stage of ABCA4 disease leading to abnormal foveal architecture. MP could be augmented by supplemental lutein in some patients. There was no change in central vision after 6 months of lutein supplementation. Long-term influences of this supplement on the natural history of these macular degenerations require further study.

Fast assessment of the central macular pigment density with natural pupil using the macular pigment reflectometer

We built a new macular pigment reflectometer (MPR) for fast and objective measuring of the optical density of macular pigment in the human eye, using the undilated eye. The design is based on the spectral reflectance from a spot of white light at the fovea. To evaluate its performance, we measured the macular pigment of 20 healthy subjects, ages 18 to 79 years, under four conditions: (1) natural pupil in the dark, (2) natural pupil with dim room light, (3) dilated pupil in the dark, and for comparison with a different technique, (4) heterochromatic flicker photometry (HFP) in dim room light with natural pupil. Condition 1 was repeated in a subset of 10 subjects after an interval of at least 3 days. Data analysis with a model of reflectors and absorbers in the eye provided the density of the macular pigment in conditions 1 to 3. Dim room light and pupil dilatation had no influence on measured density. Mean within subjects variation was typically 7%. Mean difference between test and retest after at least 3 days was 1%. Correlation between MPR and HFP was r=0.56 (p=0.012). Mean within subjects variation with HFP was 19%. The new instrument holds promise for specific applications such as epidemiological research.

Consumption of one egg per day increases serum lutein and zeaxanthin concentrations in older adults without altering serum lipid and lipoprotein cholesterol concentrations

Lutein and zeaxanthin accumulate in the macular pigment of the retina, and are reported to be associated with a reduced incidence of age-related macular degeneration. A rich source of lutein and zeaxanthin in the American diet is the yolk of chicken eggs. Thus, the objective of the study was to investigate the effect of consuming 1 egg/d for 5 wk on the serum concentrations of lutein, zeaxanthin, lipids, and lipoprotein cholesterol in individuals >60 y of age. In a randomized cross-over design, 33 men and women participated in the 18-wk study, which included one run-in and one washout period of no eggs prior to and between two 5-wk interventions of either consuming 1 egg or egg substitute/d. Serum lutein 26% (P < 0.001) and zeaxanthin 38% (P < 0.001) concentrations increased after 5-wk of 1 egg/d compared with the phase prior to consuming eggs. Serum concentrations of total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides were not affected. These findings indicate that in older adults, 5 wk of consuming 1 egg/d significantly increases serum lutein and zeaxanthin concentrations without elevating serum lipids and lipoprotein cholesterol concentrations.

Production of deuterated lutein by Chlorella protothecoides and its detection by mass spectrometric methods

Chlorella protothecoides, a lutein-producing microalga, was grown aerobically in a mineral medium prepared with 70% (v/v) deuterated water. HPLC/atmospheric pressure chemical ionization-mass spectrometry (HPLC/APCI-MS) analysis revealed approximately 58% replacement of hydrogen by deuterium atoms as indicated by the molecular mass cluster at around m/z 599. The rapidly growing microalga had much higher levels (58%) of deuterium substitution relative to previously reported (9-15%) natural sources of lutein.

Engineering ketocarotenoid biosynthesis in potato tubers

Consumption of astaxanthin is increasingly associated with a range of health benefits. Attempts to engineer ketocarotenoid biosynthesis in plants have been successful although there are no reports of nutritionally significant levels of astaxanthin in plant storage organs. Thus, in this study, ketocarotenoid biosynthesis was engineered in potato tubers. Both Solanum tuberosum and Solanum phureja transgenic lines were produced that expressed an algal bkt1 gene, encoding a beta-ketolase, and accumulated ketocarotenoids. Two major ketocarotenoids were detected, ketolutein and astaxanthin. The level of unesterified astaxanthin reached ca. 14 microg g(-1) DW in some bkt1 expressing lines of S. phureja but was much lower in the S. tuberosum background. Co-transformation of S. tuberosum with crtB, encoding phytoene synthase, and the bkt1 gene was achieved in order to determine whether this would enhance the levels of S. tuberosum ketocarotenoid.

Photooxidation of A2-PE, a photoreceptor outer segment fluorophore, and protection by lutein and zeaxanthin

A2-PE is a pigment that forms as a byproduct of the visual cycle, its synthesis from all-trans-retinal and phosphatidylethanolamine occurring in photoreceptor outer segments. A2-PE is deposited in retinal pigment epithelial (RPE) cells secondary to phagocytosis of shed outer segment membrane and it undergoes hydrolysis to generate the RPE lipofuscin fluorophores, A2E, iso-A2E and other minor cis-isomers of A2E. We have demonstrated that A2-PE can initiate photochemical processes that involve the oxidation of A2-PE and that, by analogy with A2E are likely to include the formation of reactive moieties. We also show that potential sources of protection against the photooxidation of A2-PE are the lipid-soluble carotenoids zeaxanthin and lutein (xanthophylls), that constitute the yellow pigment of the macula. Irradiation of A2-PE in the presence of lutein or zeaxanthin suppressed A2-PE photooxidation and in experiments in which we compared the antioxidant capability of zeaxanthin and lutein to alpha-tocopherol, the carotenoids were more potent. Additionally, the effect with zeaxanthin was consistently more robust than with lutein and when alpha-tocopherol was combined with either carotenoid, the outcome was additive. Lutein, zeaxanthin and alpha-tocopherol were all efficient quenchers of singlet oxygen. We have also shown that lutein and zeaxanthin can protect against A2-PE/A2E photooxidation without appreciable consumption of the carotenoid by chemical reaction. This observation contrasts with the pronounced susceptibility of A2E and A2-PE to photooxidation and is of interest since lutein, zeaxanthin, A2E and A2-PE all have conjugated systems of carbon-carbon double bonds terminating in cyclohexenyl end-groups. The structural features responsible for the differences in quenching mechanisms are discussed. It has long been suspected that macular pigment protects the retina both by filtering high-energy blue light and by serving an antioxidant function. Evidence presented here suggests that the photochemical reactions against which lutein and zeaxanthin protect, may include those initiated by the A2-PE. Quantitative HPLC analysis revealed that in eyecups of C57BL/6J and BALB/cByJ mice, levels of A2-PE were several fold greater than the cleavage product, A2E. Taken together, these results may have implications with respect to the involvement of A2-PE formation in mechanisms underlying blue light-induced photoreceptor cell damage and may be significant to retinal degenerative disorders, such as those associated with ABCA4 mutations, wherein there is a propensity for increased A2-PE synthesis.

Microbial xanthophylls

Xanthophylls are oxygenated carotenoids abundant in the human food supply. Lutein, zeaxanthin, and cryptoxanthin are major xanthophyll carotenoids in human plasma. The consumption of these xanthophylls is directly associated with reduction in the risk of cancers, cardiovascular disease, age-related macular degeneration, and cataract formation. Canthaxanthin and astaxanthin also have considerable importance in aquaculture for salmonid and crustacean pigmentation, and are of commercial interest for the pharmaceutical and food industries. Chemical synthesis is a major source for the heavy demand of xanthophylls in the consumer market; however, microbial producers also have potential as commercial sources. In this review, we discuss the biosynthesis, commercial utility, and major microbial sources of xanthophylls. We also present a critical review of current research and technologies involved in promoting microbes as potential commercial sources for mass production.

On the age dependency of the macular pigment optical density

Macular pigment may protect against age related macular degeneration (AMD), because of its capability to absorb blue light and scavenge free radicals. Since age is the major risk factor in AMD, a fundamental question to be answered is the possible age dependence of the macular pigment optical density (MPOD) in normal healthy subjects. In this study we used five methods to study a possible age effect: heterochromatic flickerphotometry, two setups for fundus reflectance spectroscopy, a Scanning Laser Ophthalmoscope (SLO) for obtaining reflectance, and the same SLO for autofluorescence maps. MPOD was determined from the reflected light by a full spectral analysis. We also used a new, directional analysis of the reflected light to estimate MPOD. The latter avoids the disturbing influence of stray-light. Digital subtraction at two wavelengths of log reflectance and digital subtraction of log autofluorescence obtained with the SLO provided MPOD maps. Together, all methods of measuring and of analysis provided seven MPOD estimates per subject. A total of 53 subjects, aged 19-76 years, completed all five measurements (and thus seven analyses). An additional 81 subjects, aged 18-70 years, were measured with one setup for fundus reflectance spectroscopy (and thus only two analyses). We could not find any association with age with all the objective techniques. Only MPOD values obtained with heterochromatic flickerphotometry showed a small, but significant decrease with age. This decrease was caused by an increase in the parafoveal data, suggesting that the central MPOD is unchanged with age. The bivariate correlation coefficients between all methods were significant (all p<0.001).

Serum levels of macular carotenoids in relation to age-related maculopathy

BACKGROUND

It has been hypothesized that the macular carotenoids, lutein and zeaxanthin, may protect against age-related maculopathy. We evaluated the association between blood concentrations of lutein (L) and zeaxanthin (Z) and age-related maculopathy (ARM) in a case-control analysis of the baseline examination of the Muenster Ageing and Retina Study (MARS).

METHODS

Of the 1060 participants aged 59-82 years at baseline, 910 (85.9%) with bilateral gradable fundus photographs and complete data for the carotenoids and potential confounders were included. The Rotterdam classification system was used for definition of ARM stages. Multivariate linear regression methods were applied to model the relationship between macular carotenoids and the presence of ARM.

RESULTS

The participants' mean age was 70.9+5.5 years, 59.9% were female, 20.8% had a normal bilateral fundus, and 48.5% showed signs of early ARM (uni- or bilateral) and 30.7% of late ARM (in at least one eye). In study participants with L and/or Z supplementation (15.6%), the median serum levels for L (Z) were approximately 2 times (1.5 times) higher than in subjects with no supplementation. After exclusion of subjects with L and/or Z supplementation, no statistically significant bivariate relationship was observed between the serum levels of L or Z and the presence of ARM. Multivariate regression models, adjusting for age, gender, smoking, body-mass index, and HDL-cholesterol blood levels, produced adjusted mean serum levels of 0.124, 0.112, and 0.131 microg/ml for L and 0.019, 0.020, and 0.022 microg/ml for Z in subjects with normal fundus, early ARM, and late ARM, respectively.

CONCLUSION

In this large study, the serum concentrations of L and Z were not related to the prevalence of ARM. However, the large proportion of study participants taking L and/or Z supplementation may have affected these results.