Dietary analysis and nutritional behaviour in people with and without age-related macular disease

Exploring the factors influencing nutritional literacy based on the socioecological model among patients with age-related macular degeneration: a qualitative study from China

OBJECTIVES

Although nutritional support is beneficial to the visual rehabilitation of patients with age-related macular degeneration (AMD), a large gap continues to exist between the relevant guidelines and the actual practices of AMD patients; this gap can be attributed to a lack of nutritional literacy. Therefore, this study explored the factors affecting nutritional literacy among AMD patients.

DESIGN

A qualitative study was carried out based on individual in-person interviews with 15 AMD patients; a semistructured interview guide was used for data collection. The socioecological model (SEM) was employed for data analysis.

SETTING

The Southwest Hospital in Chongqing Province, China.

PARTICIPANTS

A purposive sample of 15 AMD patients was recruited between May and June 2023.

RESULTS

The social ecosystem of patients with AMD has not been positive. At the intrapersonal level, the factors affecting the nutritional literacy of such patients are lack of knowledge, nutrition self-efficacy, economic burdens, dietary preferences and health status. At the interpersonal level, the factors that can influence patients' nutritional literacy are social support and social roles. At the institutional level, the relevant factors are doctor-patient trust and interdisciplinary-team consistency. Finally, at the policy level, a powerful factor is the large gap between policy and implementation.

DISCUSSION

Nutritional literacy focuses on the changes in an individual's knowledge and behaviour concerning nutrition. To inform the development of nutritional-literacy interventions for people with AMD, medical staff should consider multiple perspectives that can remove the barriers to the SEM at all levels.

Exploring challenges to nutrition intervention adherence using COM-B model among patients with wet age-related macular degeneration: a qualitative study

OBJECTIVES

To explore challenges to nutrition intervention adherence using the Capability, Opportunity and Motivation-Behaviour (COM-B) model among wet age-related macular degeneration (AMD) patients. These factors should be considered in the development of potential support and intervention programmes to address these problems.

DESIGN

A qualitative study was conducted with one-to-one and face-to-face interviews with wet AMD patients using a semi-structured question guide. Data were analysed based on COM-B model: capability (physical and psychological), opportunity (physical and social) and motivation (reflective and automatic).

SETTING

Southwest Hospital of Chongqing Province in China.

PARTICIPANTS

A convenient and purposive sample of 24 wet AMD patients were recruited.

RESULTS

The themes and subthemes were identified: psychological capability: (1) insufficient knowledge of nutrition; (2) misconceptions about the disease and treatment; (3) knowledge conflict; physical capability: (1) physical restriction; (2) limited access to nutrition knowledge; physical opportunity: (1) communication between providers and patients; (2) health insurance and extra charges; (3) food environment; social opportunity: (1) stigma of disease; (2) family influence; reflective motivation: (1) self-efficacy; (2) attitude; (3) outcome expectancies; (4) lack of professional support; automatic motivation: (1) difficulties in changing eating habits; (2) mindset.

CONCLUSION

Medical staff should pay much attention to the process of patients' nutrition intervention. In addition, it is also necessary to develop professional and internet-based intervention to modify the dietary behaviour and improve the management skills of the patients.

Development and Pilot-Testing of a Patient Decision-Making Aid for Nutrition in Age-Related Macular Degeneration

OBJECTIVE

We described the development and pilot-testing of an application based patient decision-making aid (PDA) for nutrition in age-related macular degeneration (AMD). Alpha-testing and beta-testing were performed to explore the PDA's usability, acceptability, and comprehensibility in the design stage and in "real-life" conditions.

METHODS

A nutrition PDA was developed in this study by a multidisciplinary steering committee that consisted of ophthalmologists, nurses, nutritionists, and methodologists using a systematic development process. The PDA was based on a smartphone native installation and a free-to-use app. First, based on information from literature reviews and focus group interviews for needs assessment, we developed a decision aid prototype. Second, we conducted the alpha testing to explore the acceptability, usability, and comprehensibility of the PDA prototype among 18 AMD patients. Third, a before/after study was conducted to assess changes in the attitudes, risk perceptions, intentions, knowledge, decisional conflicts, and decision self-efficacy of 33 AMD patients.

RESULTS

The alpha test proved that the nutrition PDA is acceptable and usable. In the beta test, after the AMD participants used the PDA, their scores for knowledge [mean = 13.3, standard deviation (SD) = 2.92], attitude (mean = 18.97, SD = 2.19), decision self-efficacy (mean = 23.94, SD = 6.04), and preparation significantly increased (mean = 26.30, SD = 4.90), and their score for decisional conflict significantly decreased (mean = 10.15, SD = 3.66). There was no significant difference in anxiety (mean = 2.64, SD = 1.08) before and after the use of the PDA. The mean score in the system usability scale was above 70 (mean = 72.61; SD = 5.38), which indicates the good usability of the PDA. With regard to the PDA acceptability, the scores for satisfaction with its comprehensibility, satisfaction with its attractiveness, and satisfaction with its emotional support were 5.49 (SD = 1.03), 5.30 (SD = 1.40), and 4.91(SD = 1.07), respectively, which show its adequate acceptability.

CONCLUSION

Our study showed that the nutrition PDA was an acceptable and suitable instrument for AMD patients and fit the values of all its stakeholders. This study is an important step in supporting shared decision-making, which has the potential to provide a more patient-centered and value-based nutrition health system for individuals with different types of AMD.

Treatments for dry age-related macular degeneration and Stargardt disease: a systematic review

BACKGROUND

Age-related macular degeneration (AMD) is the leading cause of visual loss in older people. Advanced AMD takes two forms, neovascular (wet) and atrophic (dry). Stargardt disease (STGD) is the commonest form of inherited macular dystrophy.

OBJECTIVE

To carry out a systematic review of treatments for dry AMD and STGD, and to identify emerging treatments where future NIHR research might be commissioned.

DESIGN

Systematic review.

METHODS

We searched MEDLINE, EMBASE, Web of Science and The Cochrane Library from 2005 to 13 July 2017 for reviews, journal articles and meeting abstracts. We looked for studies of interventions that aim to preserve or restore vision in people with dry AMD or STGD. The most important outcomes are those that matter to patients: visual acuity (VA), contrast sensitivity, reading speed, ability to drive, adverse effects of treatment, quality of life, progression of disease and patient preference. However, visual loss is a late event and intermediate predictors of future decline were accepted if there was good evidence that they are strong predictors of subsequent visual outcomes. These include changes detectable by investigation, but not necessarily noticed by people with AMD or STGD. ClinicalTrials.gov, the World Health Organization search portal and the UK Clinical Trials gateway were searched for ongoing and recently completed clinical trials.

RESULTS

The titles and abstracts of 7948 articles were screened for inclusion. The full text of 398 articles were obtained for further screening and checking of references and 112 articles were included in the final report. Overall, there were disappointingly few good-quality studies (including of sufficient size and duration) reporting useful outcomes, particularly in STGD. However we did identify a number of promising research topics, including drug treatments, stem cells, new forms of laser treatment, and implantable intraocular lens telescopes. In many cases, research is already under way, funded by industry or governments.

LIMITATIONS

In AMD, the main limitation came from the poor quality of much of the evidence. Many studies used VA as their main outcome despite not having sufficient duration to observe changes. The evidence on treatments for STGD is sparse. Most studies tested interventions with no comparison group, were far too short term, and the quality of some studies was poor.

FUTURE WORK

We think that the topics on which the Health Technology Assessment (HTA) and Efficacy Mechanism and Evaluation (EME) programmes might consider commissioning primary research are in STGD, a HTA trial of fenretinide (ReVision Therapeutics, San Diego, CA, USA), a visual cycle inhibitor, and EME research into the value of lutein and zeaxanthin supplements, using short-term measures of retinal function. In AMD, we suggest trials of fenretinide and of a potent statin. There is epidemiological evidence from the USA that the drug, levodopa, used for treating Parkinson's disease, may reduce the incidence of AMD. We suggest that similar research should be carried out using the large general practice databases in the UK. Ideally, future research should be at earlier stages in both diseases, before vision is impaired, using sensitive measures of macular function. This may require early detection of AMD by screening.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016038708.

FUNDING

The National Institute for Health Research HTA programme.

Dietary patterns were not associated with age-related macular degeneration: a cross-sectional analysis in the Irish Nun Eye Study

BACKGROUND

Analysing dietary patterns (DP) evaluates overall dietary intake, taking account of its complexity, quality, variance and the interaction between different foods, providing an alternative approach for the evaluation of nutritional influences on age-related macular degeneration (AMD) risk.

AIMS

To evaluate the relationship between DP and AMD in an older female population.

METHODS

Data was analysed from the cross-sectional Irish Nun Eye Study involving 1233 older women with a restricted lifestyle (mean age 76.3 years [range, 56-100 years). The Wisconsin Age-related Maculopathy Grading System was used to classify digital colour macular fundus images and dietary intake was assessed using a food frequency questionnaire (n = 1033). A posteriori DP were derived using principal component analysis. Logistic regression models examined associations between DP and AMD risk with adjustment for confounders.

RESULTS

Two DP were identified: a 'healthy' pattern characterised by a high intake of oily fish, wholegrains, vegetables and fruit; and an 'unhealthy' pattern characterised by high-fat dairy products, sugar, sweets and chips. Of the participants included within the analysis, AMD status were categorised as controls (n = 818, 86.9%), early AMD (n = 83, 8.8%) and late AMD (n = 21, 2.2%). Regression analysis failed to identify any significant associations between healthy or unhealthy DP and AMD risk, in unadjusted and adjusted models.

CONCLUSION

No evidence of an association between the DP identified and AMD risk was detected in this well-characterised population. Further research is required to determine the overall dietary influences on AMD risk in general population cohorts.

Role of diet and food intake in age-related macular degeneration: a systematic review

A systematic literature review was conducted to evaluate the role of diet and food intake in age-related macular degeneration (AMD). Eighteen high-quality studies were identified. Adherence to a Mediterranean diet had decreased risk of AMD progression. An Oriental diet pattern had decreased association with AMD prevalence, whereas a Western diet pattern had increased association with AMD prevalence. High consumption of vegetables rich in carotenoids and fatty fish containing omega-3 fatty acids was beneficial for those at risk of AMD. Vegetable oils and animal fats containing omega-6 fatty acids, and red/processed meat should be consumed minimally to reduce the risk of AMD progression. High glycaemic index diets and alcohol consumption of greater than two drinks a day had increased association with AMD. As the quality of diet and food intake had a vital role in AMD, the provision of appropriate nutritional advice to those at risk of AMD is recommended.

Testing the impact of an educational intervention designed to promote ocular health among people with age-related macular degeneration

Research has shown that individuals affected by age-related macular degeneration (AMD) do not always consume foods or supplements known to be beneficial for ocular health. This study tested the effectiveness of an educational intervention designed to promote healthy eating and nutritional supplementation in this group. A total of 100 individuals with AMD completed baseline measures of several variables: confidence that diet affects AMD, motivation to engage in health-protective behaviours, knowledge about which nutrients are beneficial, and intake of kale, spinach, and eggs. Participants were allocated to either intervention or control conditions. Intervention participants received a leaflet and prompt card that contained advice regarding dietary modification and supplementation. Control participants received a leaflet created by the Royal College of Optometrists. A follow-up questionnaire, measuring the same variables assessed at baseline, was administered 2 weeks later. At follow-up, significant condition × time interactions were found for confidence that diet affects AMD ( F(1, 92) = 4.54, p < .05), motivation to talk to an eye professional about supplementation ( F(1, 92) = 4.53, p = .036), motivation to eat eggs ( F(1, 92) = 12.67, p = .001), and egg intake ( F(1, 92) = 11.97, p = .001). In each case, intervention participants scored higher than control participants. Receiving an educational intervention increased participants’ confidence that diet affects AMD, motivation to engage in health-protective behaviours, and egg intake. This intervention could be easily incorporated into current clinical practice delivered by either optometrists or ophthalmologists.

Evaluation of a clinical decision-making aid for nutrition advice in age-related macular degeneration

Age-related macular disease (AMD) is a multifactorial degenerative condition affecting the central area of the retina. Patients with AMD report that eye care practitioners are not giving consistent advice regarding nutrition and reported confusion as to what advice, if any, to follow. The aim of this study was to design and conduct a preliminary evaluation of a flowchart to support eye care practitioners in providing accurate, evidence-based nutritional advice to their patients. A flowchart was designed to take practitioners through a decision-making process that would determine whether a patient matched the Age-Related Eye Disease Study (AREDS) 2 eligibility criteria for supplementation. The flowchart was evaluated using a qualified and student optometrist cohort, with both cohorts completing confidence scales and students completing clinical scenarios. Qualified participants showed a significant increase in confidence scores from the initial survey (M = 69.7%, standard deviation [SD] = 16.2%) to the second survey after use of the flowchart for 2 weeks (M = 82.1%, SD = 11.6%; t(45) = 7.33, p < .001; rs = .61, p < .001). The student participants also increased confidence scored after receiving the flowchart (M of first survey = 41.7, SD = 14.6; M of second survey = 69.1, SD = 1.7; t(25) = 7.92, d = .81, p < .001) and increased the number of correct answers on five clinical scenarios. Overall, the flowchart has proved to be useful in boosting the self-efficacy of both qualified practitioners and student practitioners, as well as improving clinical decisions made by student practitioners.