Antioxidant vitamins and nuclear opacities: the longitudinal study of cataract

Association between Healthy Eating Index-2015 and Age-Related Cataract in American Adults: A Cross-Sectional Study of NHANES 2005-2008

BACKGROUND

Healthy Eating Index-2015 (HEI-2015), a healthy eating pattern proposed by Dietary Guidelines for Americans, is proven to be protective against various diseases. However, whether it is associated with age-related cataracts is unknown.

METHODS

This population-based cross-sectional study included 6395 participants from the National Health and Nutrition Examination Survey (NHANES) in the cycles from 2005 to 2008. HEI-2015 was calculated from 24-h dietary recall interviews, ranging from 0 to 100, and higher HEI-2015 represents better diet quality. Age-related cataract was generated from the questionnaire. The association between HEI-2015 and cataract was assessed with logistic regression models. Propensity score weighting, restricted cubic spline, and subgroup analysis were conducted to further explore the relationship.

RESULTS

6395 participants were included in the study, with a mean [standard deviation (SD)] age of 48.7 (15.3) years and 3115 (48.7%) being male. HEI-2015 was negatively associated with cataracts after adjusting all covariates included, both as a continuous variable [odds ratio (OR): 0.991, 95% confidence interval (CI): 0.984-0.997, p = 0.006] and quartiles with the highest quartile compared to the lowest (OR: 0.739, 95% CI: 0.559-0.980, p = 0.035). After propensity score weighting, the association remained significant. Restricted cubic spline revealed no non-linear relationship (p for non-linearity 0.085). Subgroup analysis showed that there were no interaction effects.

CONCLUSIONS

Adherence to the healthy eating pattern, HEI-2015, was associated with a lower risk of age-related cataracts.

Reported evidence of vitamin E protection against cataract and glaucoma

Cataract and glaucoma are the major causes of severe visual loss and blindness in older adults. This review article describes the currently available basic and clinical evidence regarding vitamin E protection against these eye diseases in the chronologic order of the publications. Experimental evidence has suggested both that oxidative stress due to the accumulation of free radicals plays a role in the pathogenesis of cataracts and glaucoma and that the process can be prevented or ameliorated by vitamin E. The results of observational studies have been inconsistent regarding the association between blood vitamin E levels and the risk of age-related cataract or glaucoma. Despite the encouraging effects of vitamin E from case series, case-control studies, and cross-sectional studies in humans, the effects on cataract formation and/or progression have not been consistent among prospective and randomized control studies; few randomized control studies have tested the effects of supplemental vitamin E on glaucoma development or progression. Given the high prevalence of cataract and glaucoma in the elderly population, even a modest reduction in the risk for these eye diseases would potentially have a substantial public health impact; however, the potential benefits of vitamin E on cataract or glaucoma remain inconclusive and need to be carefully considered.

Vitamin E: How much is enough, too much and why!

α-Tocopherol (α-T) is a required dietary nutrient for humans and thus is a vitamin. This narrative review focuses on vitamin E structures, functions, biological determinants and its deficiency symptoms in humans. The mechanisms for the preferential α-T tissue enrichment in the human body include the α-T transfer protein (TTPA) and the preferential metabolism of non-α-T forms. Potential new α-T biomarkers, pharmacokinetic data, and whether there are better approaches to evaluate and set the α-T dietary requirement are discussed. Finally, the possible role of α-T supplements in delay of chronic diseases and the evaluation of vitamin E safety are considered.

Diet and risk of visual impairment: a review of dietary factors and risk of common causes of visual impairment

Age-related macular degeneration, diabetic retinopathy, cataract, and glaucoma remain the leading causes of visual impairment in developed nations, resulting in a substantial treatment burden on sufferers and health care systems. Despite significant advances in diagnostic testing and therapeutics, population-based strategies to reduce the burden of these diseases remain limited. However, there is some evidence that these diseases may share overlapping risk factors, particularly in regard to dietary intake and antioxidant status, and it is thus possible that dietary modification may reduce both the prevalence and severity of these conditions. In particular, dietary intake of green leafy vegetables, hyperglycemia/glycemia index, and omega-3 fatty acid intake, as well as overall dietary patterns, may affect risk of one or more of these conditions. In this review, we analyse the evidence for dietary intake and the association with these conditions, and provide insights into possible modifications that may thus simultaneously reduce the risk of visual impairment from multiple causes, including improving dietary intake of green leafy vegetables and reducing dietary glycemic index, both of which have been associated with a decreased risk of multiple causes of visual impairment.

The Combination of Healthy Diet and Healthy Body Weight Is Associated with Lower Risk of Nuclear Cataract in the Blue Mountains Eye Study

BACKGROUND

Greater adherence to dietary guidelines has previously been found to be associated with decreased risk of visual impairment. However, whether or not this association extends to age-related cataract, 1 of the leading causes of visual impairment, is unknown.

OBJECTIVES

The aim of this study was to assess the association between adherence to dietary guidelines, using total diet score, and incidence of age-related cataract.

METHODS

Of 3654 baseline participants of the population-based Blue Mountains Eye Study cohort (1992-1994), 2334 (75.8% survivors) and 1952 (76.7% survivors) were examined after 5 and 10 y, respectively. Cataract was assessed from lens photographs using the Wisconsin Cataract Grading System. Baseline total diet score was calculated from FFQ data following a modified version of the Healthy Eating Index for Australians. OR with 95% CI were estimated using discrete logistic regression analyses, adjusting for age, sex, and other confounders. To test interaction, a cross-product term of 2 factors was included in regression models.

RESULTS

Of 2173 participants (84.7% of those returned for 1 or both follow-ups) with total diet score estimated, 57% were women, mean baseline age was 63.9 ± 8.4y, and mean baseline BMI was 26.3 ± 4.3 kg/m2. After multivariable adjustment, baseline total diet score was not associated with incidence of any cataract. A multiplicative interaction was observed between total diet score and BMI for incident nuclear cataract (P-interaction = 0.04): increasing baseline total diet score was associated with decreased risk of nuclear cataract among participants with BMI <25 (per unit increased total diet score, OR: 0.90; 95% CI: 0.81, 0.99; P = 0.02), but not among participants with BMI ≥25 (OR: 1.00; 95% CI: 0.92, 1.10; P = 0.95).

CONCLUSIONS

Adherence to dietary guidelines had no appreciable influence on cataract development overall in this older Australian population. However, adherence to dietary guidelines combined with healthy BMI is associated with decreased risk of nuclear cataract, an aging marker.

A focus on resveratrol and ocular problems, especially cataract: From chemistry to medical uses and clinical relevance

Low vision and blindness are important health problems that affect millions of people throughout the world. The most common and important pathologies are diabetic retinopathy, age-related macular degeneration, glaucoma as well as cataracts. The latter consists of an opacification of the lens of the eye which impedes the passage of light and represents one of the most important causes of vision loss. Among the risk factors for cataract development, there are life-style factors such as the use of tobacco, abuse of alcohol and unhealthy diet. In light of this, dietary components that possess anti-oxidant activity, such as polyphenols for instance, can be considered good candidates for human studies in the prevention and or treatment of such diseases. Among dietary components, the antioxidant capacity of certain polyphenols is well known, and these could be good candidates. In this review we focus our attention on the current scientific literature regarding to the effects of resveratrol on cataracts and other ocular diseases, along with its potential mechanism/s of action. A large number of preclinical studies support the involvement of resveratrol in clinical trials for the prevention and treatment of eye diseases induced by oxidative stress and inflammation, such as age-related cataract.

Genetic and Dietary Factors Influencing the Progression of Nuclear Cataract

Purpose

To determine the heritability of nuclear cataract progression and to explore prospectively the effect of dietary micronutrients on the progression of nuclear cataract.

Design

Prospective cohort study.

Participants

Cross-sectional nuclear cataract and dietary measurements were available for 2054 white female twins from the TwinsUK cohort. Follow-up cataract measurements were available for 324 of the twins (151 monozygotic and 173 dizygotic twins).

Methods

Nuclear cataract was measured using a quantitative measure of nuclear density obtained from digital Scheimpflug images. Dietary data were available from EPIC food frequency questionnaires. Heritability was modeled using maximum likelihood structural equation twin modeling. Association between nuclear cataract change and micronutrients was investigated using linear and multinomial regression analysis. The mean interval between baseline and follow-up examination was 9.4 years.

Main Outcome Measures

Nuclear cataract progression.

Results

The best-fitting model estimated that the heritability of nuclear cataract progression was 35% (95% confidence interval [CI], 13–54), and individual environmental factors explained the remaining 65% (95% CI, 46–87) of variance. Dietary vitamin C was protective against both nuclear cataract at baseline and nuclear cataract progression (β = −0.0002, P = 0.01 and β = −0.001, P = 0.03, respectively), whereas manganese and intake of micronutrient supplements were protective against nuclear cataract at baseline only (β = −0.009, P = 0.03 and β = −0.03, P = 0.01, respectively).

Conclusions

Genetic factors explained 35% of the variation in progression of nuclear cataract over a 10-year period. Environmental factors accounted for the remaining variance, and in particular, dietary vitamin C protected against cataract progression assessed approximately 10 years after baseline.

Lutein, Zeaxanthin, and meso-Zeaxanthin in the Clinical Management of Eye Disease

Lutein, zeaxanthin, and meso-zeaxanthin are xanthophyll carotenoids found within the retina and throughout the visual system. The retina is one of the most metabolically active tissues in the body. The highest concentration of xanthophylls is found within the retina, and this selective presence has generated many theories regarding their role in supporting retinal function. Subsequently, the effect of xanthophylls in the prevention and treatment of various eye diseases has been examined through epidemiological studies, animal studies, and clinical trials. This paper attempts to review the epidemiological studies and clinical trials investigating the effects of xanthophylls on the incidence and progression of various eye diseases. Observational studies have reported that increased dietary intake and higher serum levels of lutein and zeaxanthin are associated with lower risk of age-related macular degeneration (AMD), especially late AMD. Randomized, placebo-controlled clinical trials have demonstrated that xanthophyll supplementation increases macular pigment levels, improves visual function, and decreases the risk of progression to late AMD, especially neovascular AMD. Current publications on the preventive and therapeutic effects of lutein and zeaxanthin on cataracts, diabetic retinopathy, and retinopathy of prematurity have reported encouraging results.

The Association of Dietary Lutein plus Zeaxanthin and B Vitamins with Cataracts in the Age-Related Eye Disease Study: AREDS Report No. 37

PURPOSE

To evaluate whether dietary intake of luteiin/zeaxanthin and B vitamins is associated with cataract prevalence and incidence.

DESIGN

Clinic-based, baseline cross-sectional and prospective cohort study designs.

PARTICIPANTS

Three thousand one hundred fifteen patients (6129 eyes) enrolled in the Age-Related Eye Disease Study 55 to 80 years of age followed up for mean of 9.6 years.

METHODS

Participants completed baseline food frequency questionnaires. Baseline and annual lens photographs were graded centrally. Multivariate models controlling for previously identified risk factors for cataracts tested for the association of cataracts with reported dietary intake, using the lowest quintile as reference.

MAIN OUTCOME MEASURES

Cataract surgery, cataract status (type and severity) at baseline, and development of cataracts.

RESULTS

At baseline, increased dietary riboflavin and B12 were associated inversely with nuclear and cortical lens opacities. In comparisons of persons with and without cataract, persons with the highest riboflavin intake versus those with the lowest intake had the following associations: mild nuclear cataract: odds ratio (OR), 0.78; 95% confidence interval (CI), 0.63-0.97; moderate nuclear cataract: OR, 0.62; 95% CI, 0.43-0.90; and mild cortical cataract: OR, 0.80; 95% CI, 0.65-0.99. For B12, the results were: mild nuclear cataract: OR, 0.78; 95% CI, 0.63-0.96; moderate nuclear cataract: OR, 0.62; 95% CI, 0.43-0.88; and mild cortical cataract: OR, 0.77; 95% CI, 0.63-0.95. Highest dietary B6 intake was associated with a decreased risk of moderate nuclear lens opacity developing compared with the lowest quintile (OR, 0.67; 95% CI, 0.45-0.99). Highest dietary intake levels of niacin and B12 were associated with a decreased risk of development of mild nuclear or mild cortical cataracts in participants not taking Centrum (Pfizer, New York, NY) multivitamins. For participants taking multivitamins during the study, the highest intake of dietary folate was associated with an increased risk of mild posterior subcapsular lens opacity development. No statistically significant associations were found between lutein plus zeaxanthin intake and presence at baseline or development of nuclear or cortical lens opacity outcomes.

CONCLUSIONS

These findings are consistent with earlier studies suggesting that dietary intake of B vitamins may affect the occurrence of age-related lens opacities. Further investigations are warranted.

Nutrient Supplementation for Age-related Macular Degeneration, Cataract, and Dry Eye

There have been enormous advances in the past decade for the treatment of age-related macular degeneration (AMD); however, these treatments are expensive and require frequent follow-up and injections which place a tremendous burden on both the healthcare system and patients. Consequently, there remains considerable interest in preventing or slowing the progression of AMD requiring treatment. Epidemiological studies have shown that diet is a modifiable AMD risk factor, and nutrient modification is a particularly appealing treatment for AMD due to the perceived universal benefit and relatively low expense. Recently, the age-related eye disease study part two (AREDS2) was concluded and demonstrated further benefit with the addition of lutein and zeaxanthin as a replacement for the β-carotene of the previous generation formulation. The addition of omega-3 essential fatty acids did not show an added benefit. This review aims to highlight some of the evidenced based body of knowledge that has been accumulated from recent studies regarding the use of nutritional supplements and their effect on AMD, cataracts, and dry eyes.

Vitamin E and risk of age-related cataract: a meta-analysis

Objective

We conducted a meta-analysis to evaluate the relationship between vitamin E and age-related cataract (ARC).

Design

The fixed- or random-effect model was selected based on heterogeneity. Meta-regression was used to explore potential sources of between-study heterogeneity. Publication bias was evaluated using Begg’s test. The dose–response relationship was assessed by a restricted cubic spline model.

Setting

Relevant studies were identified by a search of PubMed and the Cochrane Library to May 2014, without language restrictions.

Subjects

Studies involved samples of people of all ages.

Results

Dietary vitamin E intake, dietary and supplemental vitamin E intake, and high serum tocopherol levels were significantly associated with decreased risk of ARC, the pooled relative risk was 0·73 (95 % CI 0·58, 0·92), 0·86 (95 % CI 0·75, 0·99) and 0·77 (95 % CI 0·66, 0·91), respectively. Supplemental vitamin E intake was non-significantly associated with ARC risk (relative risk=0·92; 95 % CI 0·78, 1·07). The findings from dose–response analysis showed evidence of a non-linear association between dietary vitamin E intake and ARC. The risk of ARC decreased with dietary vitamin E intake from 7 mg/d (relative risk=0·94; 95 % CI 0·90, 0·97).

Conclusions

The findings of the meta-analysis indicated that dietary vitamin E intake, dietary and supplemental vitamin E intake, and high level of serum tocopherol might be significantly associated with reduced ARC risk.

A phytochemical-rich diet may explain the absence of age-related decline in visual acuity of Amazonian hunter-gatherers in Ecuador

Myopia is absent in undisturbed hunter-gatherers but ubiquitous in modern populations. The link between dietary phytochemicals and eye health is well established, although transition away from a wild diet has reduced phytochemical variety. We hypothesized that when larger quantities and greater variety of wild, seasonal phytochemicals are consumed in a food system, there will be a reduced prevalence of degenerative-based eye disease as measured by visual acuity. We compared food systems and visual acuity across isolated Amazonian Kawymeno Waorani hunter-gatherers and neighboring Kichwa subsistence agrarians, using dietary surveys, dietary pattern observation, and Snellen Illiterate E visual acuity examinations. Hunter-gatherers consumed more food species (130 vs. 63) and more wild plants (80 vs. 4) including 76 wild fruits, thereby obtaining larger variety and quantity of phytochemicals than agrarians. Visual acuity was inversely related to age only in agrarians (r = -.846, P < .001). As hypothesized, when stratified by age (<40 and ≥ 40 years), Mann-Whitney U tests revealed that hunter-gatherers maintained high visual acuity throughout life, whereas agrarian visual acuity declined (P values < .001); visual acuity of younger participants was high across the board, however, did not differ between groups (P > .05). This unusual absence of juvenile-onset vision problems may be related to local, organic, whole food diets of subsistence food systems isolated from modern food production. Our results suggest that intake of a wider variety of plant foods supplying necessary phytochemicals for eye health may help maintain visual acuity and prevent degenerative eye conditions as humans age.

The effect of multivitamin/mineral supplements on age-related cataracts: a systematic review and meta-analysis

Antioxidant vitamins supplements have been suggested as a strategy to decrease the risk of age-related cataract development. However, the results from observational studies and interventional trials of associations between antioxidant vitamins A, C, and E and cataract development have been inconsistent. We aim to evaluate the effectiveness of multivitamin/mineral supplements for decreasing the risk of age-related cataracts by conducting a systematic review and meta-analysis. In September 2013, we searched multiple databases to identify relevant studies including both cohort studies and randomized controlled trials (RCTs). A random-effects model was used to calculate the pooled relative risks (RR) with a 95% confidence interval (CI). Twelve prospective cohort studies and two RCTs were included. Pooled results from the cohort studies indicated that multivitamin/mineral supplements have a significant beneficial effect in decreasing the risk of nuclear cataracts (RR: 0.73; 95% CI: 0.64-0.82), cortical cataracts (RR: 0.81; 95% CI: 0.68-0.94), and any cataracts (RR: 0.66; 95% CI: 0.39-0.93). In addition, there were no decreases in the risk of posterior capsular cataracts (RR: 0.96; 95% CI: 0.72-1.20) or cataract surgery (RR: 1.00; 95% CI: 0.92-1.08). The two RCTs demonstrated that multivitamin/mineral supplements could decrease the risk of nuclear cataracts. There is sufficient evidence to support the role of dietary multivitamin/mineral supplements for the decreasing the risk of age-related cataracts.

Nutrition effects on ocular diseases in the aging eye

PURPOSE

We reviewed the data from the clinical trials of nutritional supplements for the treatment of age-related cataract and age-related macular degeneration (AMD) to determine future directions of research and treatment.

METHODS

Data from the controlled clinical trials are presented and reviewed for potential opportunities for further research into the treatment of cataracts and AMD.

RESULTS

Two trials using daily multivitamins/minerals demonstrated a reduction in the progression of nuclear cataract, but increased the risk of posterior subcapsular cataract. For AMD, the Age-Related Eye Disease Study (AREDS) formulation (vitamins C, E, beta-carotene, zinc, and copper) reduced the risk of progression to advanced AMD by 25% at 5 years. Because beta-carotene is associated with increased lung cancer in former smokers, lutein/zeaxanthin could replace beta-carotene and provide an incremental increase in the beneficial effects beyond the effects of the AREDS formulation. In addition, a randomized clinical trial of B vitamins demonstrated a beneficial effect for AMD with the vitamin B complex.

CONCLUSIONS

Future evaluation may include additional assessments of nutrients for the treatment of progression of cataract and AMD. A modest reduction would have significant impact as the numbers of persons affected with these two leading causes of blindness are projected to double in the next decade. An important step would be to develop surrogate outcomes to increase efficiency in clinical trials. More detailed phenotyping, especially of AMD, is required as it appears to be not one disease, but a group of diseases. Genotype-phenotype analyses may help to target pathways that are important in AMD.

Lutein/zeaxanthin for the treatment of age-related cataract: AREDS2 randomized trial report no. 4

IMPORTANCE

Age-related cataract is a leading cause of visual impairment in the United States. The prevalence of age-related cataract is increasing, with an estimated 30.1 million Americans likely to be affected by 2020.

OBJECTIVE

To determine whether daily oral supplementation with lutein/zeaxanthin affects the risk for cataract surgery.

DESIGN, SETTING, AND PATIENTS

The Age-Related Eye Disease Study 2 (AREDS2), a multicenter, double-masked clinical trial, enrolled 4203 participants, aged 50 to 85 years, at risk for progression to advanced age-related macular degeneration.

INTERVENTIONS

Participants were randomly assigned to daily placebo; lutein/zeaxanthin, 10mg/2mg; omega-3 long-chain polyunsaturated fatty acids, 1 g; or a combination to evaluate the effects on the primary outcome of progression to advanced age-related macular degeneration.

MAIN OUTCOMES AND MEASURES

Cataract surgery was documented at annual study examination with the presence of pseudophakia or aphakia, or reported during telephone calls at 6-month intervals between study visits. Annual best-corrected visual acuity testing was performed. A secondary outcome of AREDS2 was to evaluate the effects of lutein/zeaxanthin on the subsequent need for cataract surgery.

RESULTS

A total of 3159 AREDS2 participants were phakic in at least 1 eye and 1389 of 6027 study eyes underwent cataract surgery during the study, with median follow-up of 4.7 years. The 5-year probability of progression to cataract surgery in the no lutein/zeaxanthin group was 24%. For lutein/zeaxanthin vs no lutein/zeaxanthin, the hazard ratios for progression to cataract surgery was 0.96 (95% CI, 0.84-1.10; P = .54). For participants in the lowest quintile of dietary intake of lutein/zeaxanthin, the hazard ratio comparing lutein/zeaxanthin vs no lutein/zeaxanthin for progression to cataract surgery was 0.68 (95% CI, 0.48-0.96; P = .03). The hazard ratio for 3 or more lines of vision loss was 1.03 (95% CI, 0.93-1.13; P = .61 for lutein/zeaxanthin vs no lutein/zeaxanthin).

CONCLUSIONS AND RELEVANCE

Daily supplementation with lutein/zeaxanthin had no statistically significant overall effect on rates of cataract surgery or vision loss.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00345176.

Fruit and vegetable intake and vitamins C and E are associated with a reduced prevalence of cataract in a Spanish Mediterranean population

BACKGROUND

Cataract is among the major causes of vision impairment and blindness worldwide. Epidemiological studies support the role of antioxidants in the etiology of cataract, but the evidence for one specific antioxidant over another is inconsistent. Few studies have examined the association of cataract with fruit and vegetable intake with inconclusive results. In the present study, the relationship between cataract and fruit and vegetable intake and dietary and blood levels of carotenoids, vitamins C and E were examined in a Spanish Mediterranean population.

METHODS

The present work is an analysis of data from 599 elderly ( ≥ 65 years) participants from the Spanish segment of the EUREYE study. This is a European multi-center cross-sectional population-based study. Cataract was diagnosed using a slit-lamp examination and defined as any lens opacity in either eye or evidence of its removal (cataract extraction). Energy-adjusted intake of fruit and vegetables and antioxidant vitamins was estimated using a semi-quantitative food frequency questionnaire. Plasma concentrations of vitamin C were analyzed by a colorimetric method and carotenoids and α-tocopherol by a HPLC method. The associations between cataract and quartiles of fruit and vegetable intake and plasma antioxidants were investigated using logistic regression models.

RESULTS

Of the 599 elderly recruited, 433 (73%) had cataract or cataract extraction, 54% were women and 46% were men. After adjustments, increasing quartiles of combined fruit and vegetable intake were associated with decreasing reduction of odds of cataract or cataract extraction, (P for trend = 0.008). Increasing quartiles of dietary intakes from 107 mg/d of vitamin C showed a significant decreasing association with prevalence of cataract or cataract extraction (P for trend = 0.047). For vitamin E, a protective association was found from intakes from 8 mg/d, but no linear trend was observed across quartiles of intake (P for trend = 0.944).

CONCLUSIONS

High daily intakes of fruit and vegetables and vitamins C and E were associated with a significantly decreased of the prevalence of cataract or cataract surgery. This study reinforces the WHO recommendations on the benefits of diets rich in fruit and vegetables.

Association of blood antioxidants and vitamins with risk of age-related cataract: a meta-analysis of observational studies

BACKGROUND

Observational studies have been inconsistent regarding the association between blood antioxidants or vitamins and risk of age-related cataract.

OBJECTIVE

We performed a meta-analysis to determine whether an association exists between blood levels of antioxidants or vitamins and age-related cataract in observational studies.

DESIGN

We searched PubMed, EMBASE, and the Web of Science for relevant studies from inception to October 2012. Study-specific risk estimates were combined by using a random-effects model.

RESULTS

A total of 13 studies with 18,999 participants were involved in this meta-analysis. A pooled estimate showed vitamin E (OR: 0.75; 95% CI: 0.58, 0.96), α-carotene (OR: 0.72; 95% CI: 0.59, 0.88), lutein (OR: 0.75; 95% CI: 0.65, 0.87), and zeaxanthin (OR: 0.70; 95% CI: 0.60, 0.82) were inversely associated with age-related cataract. Vitamins A (OR: 0.69; 95% CI: 0.58, 0.83) and C (OR: 0.67; 95% CI: 0.57, 0.78) were inversely associated with age-related cataract in Asian populations but not in Western populations. β-Carotene (OR: 0.90; 95% CI: 0.78, 1.05), lycopene (OR: 0.86; 95% CI: 0.65, 1.15), and β-cryptoxanthin (OR: 0.83; 95% CI: 0.68, 1.02) had no significant association with risk of cataract.

CONCLUSIONS

This meta-analysis provides additional evidence supporting the view that blood levels of certain antioxidants are inversely associated with risk of age-related cataract. However, the role of antioxidant or vitamin supplement intake in preventing cataract should be further investigated in interventional studies.

High-dose supplements of vitamins C and E, low-dose multivitamins, and the risk of age-related cataract: a population-based prospective cohort study of men

We examined the associations of high-dose supplements of vitamins C and E and low-dose multivitamins with the risk of age-related cataract among 31,120 Swedish men, aged 45-79 years, in a population-based prospective cohort. Dietary supplement use was assessed from a questionnaire at baseline in 1998. During follow-up (January 1998-December 2006), 2,963 incident age-related cataract cases were identified. The multivariable-adjusted hazard ratio for men using vitamin C supplements only was 1.21 (95% confidence interval (CI): 1.04, 1.41) in a comparison with that of non-supplement users. The hazard ratio for long-term vitamin C users (≥10 years before baseline) was 1.36 (95% CI: 1.02, 1.81). The risk of cataract with vitamin C use was stronger among older men (>65 years) (hazard ratio = 1.92, 95% CI: 1.41, 2.60) and corticosteroid users (hazard ratio = 2.11, 95% CI: 1.48, 3.02). The hazard ratio for vitamin E use only was 1.59 (95% CI: 1.12, 2.26). Use of multivitamins only or multiple supplements in addition to vitamin C or E was not associated with cataract risk. These results suggest that the use of high-dose (but not low-dose) single vitamin C or E supplements may increase the risk of age-related cataract. The risk may be even higher among older men, corticosteroid users, and long-term users.

Antioxidant vitamin supplementation for preventing and slowing the progression of age-related cataract

BACKGROUND

Age-related cataract is a major cause of visual impairment in the elderly. Oxidative stress has been implicated in its formation and progression. Antioxidant vitamin supplementation has been investigated in this context.

OBJECTIVES

To assess the effectiveness of antioxidant vitamin supplementation in preventing and slowing the progression of age-related cataract.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 2), MEDLINE (January 1950 to March 2012), EMBASE (January 1980 to March 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to March 2012), Open Grey (System for Information on Grey Literature in Europe) (www.opengrey.eu/), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 2 March 2012. We also checked the reference lists of included studies and ongoing trials and contacted investigators to identify eligible randomized trials.

SELECTION CRITERIA

We included only randomized controlled trials in which supplementation with one or more antioxidant vitamins (beta-carotene, vitamin C and vitamin E) in any form, dosage or combination for at least one year was compared to another antioxidant vitamin or to placebo.

DATA COLLECTION AND ANALYSIS

Two authors extracted data and assessed trial quality independently. We pooled results for the primary outcomes, i.e., incidence of cataract and incidence of cataract extraction. We did not pool results of the secondary outcomes - progression of cataract and loss of visual acuity, because of differences in definitions of outcomes and data presentation. We pooled results by type of cataract when data were available. We did not perform a sensitivity analysis.

MAIN RESULTS

Nine trials involving 117,272 individuals of age 35 years or older are included in this review. The trials were conducted in Australia, Finland, India, Italy, the United Kingdom and the United States, with duration of follow-up ranging from 2.1 to 12 years. The doses of antioxidant vitamins were higher than the recommended daily allowance. There was no evidence of effect of antioxidant vitamin supplementation in reducing the risk of cataract, cataract extraction, progression of cataract or in slowing the loss of visual acuity. In the pooled analyses, there was no evidence of effect of beta-carotene supplementation in reducing the risk of cataract (two trials) (relative risk (RR) 0.99, 95% confidence interval (CI) 0.91 to 1.08; n = 57,703) or in reducing the risk of cataract extraction (three trials) (RR 1.00, 95% CI 0.91 to 1.10; n = 86,836) or of vitamin E supplementation in reducing the risk of cataract (three trials) (RR 0.97, 95% CI 0.91 to 1.04; n = 50,059) or of cataract extraction (five trials) (RR 0.98, 95% CI 0.91 to 1.05; n = 83,956). The proportion of participants developing hypercarotenodermia (yellowing of skin) while on beta-carotene ranged from 7.4% to 15.8%.

AUTHORS' CONCLUSIONS

There is no evidence from RCTs that supplementation with antioxidant vitamins (beta-carotene, vitamin C or vitamin E) prevents or slows the progression of age-related cataract. We do not recommend any further studies to examine the role of antioxidant vitamins beta-carotene, vitamin C and vitamin E in preventing or slowing the progression of age-related cataract. Costs and adverse effects should be weighed carefully with unproven benefits before recommending their intake above recommended daily allowances.

Risk factors associated with incident cataracts and cataract surgery in the Age-related Eye Disease Study (AREDS): AREDS report number 32

OBJECTIVE

To investigate potential risk factors associated with incident nuclear, cortical, and posterior subcapsular (PSC) cataracts and cataract surgery in participants in the Age-Related Eye Disease Study (AREDS).

DESIGN

Clinic-based prospective cohort study.

PARTICIPANTS

Persons (n = 4425) 55 to 80 years of age enrolled in a controlled clinical trial of antioxidant vitamins and minerals, AREDS, for age-related macular degeneration and cataract.

METHODS

Lens photographs were graded centrally for nuclear, cortical, and PSC opacities using the AREDS system for classifying cataracts. Type-specific incident cataracts were defined as an increase in cataract grade from none or mild at baseline to a grade of moderate at follow-up, also with a grade of at least moderate at the final visit, or cataract surgery. Cox regression analyses were used to assess baseline risk factors associated with type-specific opacities and cataract surgery.

MAIN OUTCOME MEASURES

Moderate cataract was defined as a grade of 4.0 or more for nuclear opacity, 10% or more involvement within the full visible lens for cortical opacity, and 5% or more involvement of the central 5-mm circle of the lens for PSC opacity. These were graded on baseline and annual lens photographs.

RESULTS

A clinic-based cohort of 4425 persons 55 to 80 years of age at baseline was followed up for an average of 9.8±2.4 years. The following associations were found: increasing age with increased risk of all types of cataract and cataract surgery; males with increased risk of PSC and decreased risk of cortical cataracts; nonwhite persons with increased risk of cortical cataract; hyperopia with decreased risk of PSC, nuclear cataract, and cataract surgery; Centrum (Wyeth Consumer Healthcare, Madison, NJ) use with decreased risk of nuclear cataract; diabetes with increased risk of cortical, PSC cataract, and cataract surgery; higher educational level with decreased risk of cortical cataract; and smoking with increased risk of cortical cataract and cataract surgery. Estrogen replacement therapy in female participants increased the risk of cataract surgery.

CONCLUSIONS

These findings largely are consistent with the results of previous studies, providing further evidence for possible modifiable risk factors for age-related cataract.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Inverse association of vitamin C with cataract in older people in India

Objective

To examine the association between vitamin C and cataract in the Indian setting.

Design

Population-based cross-sectional analytic study.

Participants

A total of 5638 people aged ≥60 years.

Methods

Enumeration of randomly sampled villages in 2 areas of north and south India to identify people aged ≥60 years. Participants were interviewed for socioeconomic and lifestyle factors (tobacco, alcohol, household cooking fuel, work, and diet); attended a clinical examination, including lens photography; and provided a blood sample for antioxidant analysis. Plasma vitamin C was measured using an enzyme-based assay in plasma stabilized with metaphosphoric acid, and other antioxidants were measured by reverse-phase high-pressure liquid chromatography.

Main Outcome Measures

Cataract and type of cataract were graded from digital lens images using the Lens Opacity Classification System III (LOCS III), and cataract was classified from the grade in the worse eye of ≥4 for nuclear cataract, ≥3 for cortical cataract, and ≥2 for posterior subcapsular cataract (PSC). Any cataract was defined as any unoperated or operated cataract.

Results

Of 7518 enumerated people, 5638 (75%) provided data on vitamin C, antioxidants, and potential confounders. Vitamin C was inversely associated with cataract (adjusted odds ratio [OR] for highest to lowest quartile = 0.61; 95% confidence interval (CI), 0.51–0.74; P=1.1×10⁻⁶). Inclusion of other antioxidants in the model (lutein, zeaxanthin, retinol, β-carotene, and α-tocopherol) made only a small attenuation to the result (OR 0.68; 95% CI, 0.57–0.82; P < 0.0001). Similar results were seen with vitamin C by type of cataract: nuclear cataract (adjusted OR 0.66; CI, 0.54–0.80; P < 0.0001), cortical cataract (adjusted OR 0.70; CI, 0.54–0.90; P < 0.002), and PSC (adjusted OR 0.58; CI, 0.45–0.74; P < 0.00003). Lutein, zeaxanthin, and retinol were significantly inversely associated with cataract, but the associations were weaker and not consistently observed by type of cataract. Inverse associations were also observed for dietary vitamin C and cataract.

Conclusions

We found a strong association with vitamin C and cataract in a vitamin C–depleted population.

Financial Disclosure(s)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Dose-response relationship for α-tocopherol prevention of ultraviolet radiation induced cataract in rat

The purpose of this study is to establish the dose response relationship for α-tocopherol protection of ultraviolet radiation (UVR) induced cataract in the rat. Four groups of 20 six-week-old albino Sprague Dawley rats received 5, 25, 50, and 100 IU/day α-tocopherol, whilst another group of 20 rats without any α-tocopherol feeding was the control group. After 4 weeks of feeding, each rat was unilaterally exposed to 8 kJ/m(2) UVR-300 nm for 15 min. At 1 week after exposure, the rats were sacrificed and lens light scattering was measured quantitatively. Lens total reduced (GSH) and oxidized (GSSG) glutathione; glutathione reductase (GR) and peroxidase (GPx) were determined spectrophotometrically. The UVR-exposed lenses in the α-tocopherol fed groups developed superficial cataract, whereas lenses in the control group developed cortical and equatorial opacities. Light scattering in lenses from the α-tocopherol-supplemented rats was lower than in lenses from the control group. The difference of light scattering between the exposed and contralateral non-exposed lens decreased with increasing doses of α-tocopherol to an asymptote level. UVR-exposure caused a significant depletion of lens GSH in rats without or at low α-tocopherol supplementation. The depletion of GSH became less with higher α-tocopherol supplementation. There was no detectable difference in lens GSSG, GR or GPx at any level of α-tocopherol supplementation. Orally administered α-tocopherol dose dependently protects against UVR-induced cataract. The protection is associated with an α-tocopherol dose-dependent GSH depletion secondary to UVR exposure. UVR-induced light scattering only occurs if the GSH depletion exceeds a threshold.

Age-related cataract in a randomized trial of vitamins E and C in men

OBJECTIVE

To test whether supplementation with alternate-day vitamin E or daily vitamin C affects the incidence of age-related cataract in a large cohort of men.

METHODS

In a randomized, double-masked, placebo-controlled trial, 11,545 apparently healthy US male physicians 50 years or older without a diagnosis of cataract at baseline were randomly assigned to receive 400 IU of vitamin E or placebo on alternate days and 500 mg of vitamin C or placebo daily.

MAIN OUTCOME MEASURE

Incident cataract responsible for a reduction in best-corrected visual acuity to 20/30 or worse based on self-report confirmed by medical record review.

APPLICATION TO CLINICAL PRACTICE

Long-term use of vitamin E and C supplements has no appreciable effect on cataract.

RESULTS

After 8 years of treatment and follow-up, 1174 incident cataracts were confirmed. There were 579 cataracts in the vitamin E-treated group and 595 in the vitamin E placebo group (hazard ratio, 0.99; 95% confidence interval, 0.88-1.11). For vitamin C, there were 593 cataracts in the treated group and 581 in the placebo group (hazard ratio, 1.02; 95% confidence interval, 0.91-1.14).

CONCLUSION

Long-term alternate-day use of 400 IU of vitamin E and daily use of 500 mg of vitamin C had no notable beneficial or harmful effect on the risk of cataract.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00270647.

A review of fatty acid profiles and antioxidant content in grass-fed and grain-fed beef

Growing consumer interest in grass-fed beef products has raised a number of questions with regard to the perceived differences in nutritional quality between grass-fed and grain-fed cattle. Research spanning three decades suggests that grass-based diets can significantly improve the fatty acid (FA) composition and antioxidant content of beef, albeit with variable impacts on overall palatability. Grass-based diets have been shown to enhance total conjugated linoleic acid (CLA) (C18:2) isomers, trans vaccenic acid (TVA) (C18:1 t11), a precursor to CLA, and omega-3 (n-3) FAs on a g/g fat basis. While the overall concentration of total SFAs is not different between feeding regimens, grass-finished beef tends toward a higher proportion of cholesterol neutral stearic FA (C18:0), and less cholesterol-elevating SFAs such as myristic (C14:0) and palmitic (C16:0) FAs. Several studies suggest that grass-based diets elevate precursors for Vitamin A and E, as well as cancer fighting antioxidants such as glutathione (GT) and superoxide dismutase (SOD) activity as compared to grain-fed contemporaries. Fat conscious consumers will also prefer the overall lower fat content of a grass-fed beef product. However, consumers should be aware that the differences in FA content will also give grass-fed beef a distinct grass flavor and unique cooking qualities that should be considered when making the transition from grain-fed beef. In addition, the fat from grass-finished beef may have a yellowish appearance from the elevated carotenoid content (precursor to Vitamin A). It is also noted that grain-fed beef consumers may achieve similar intakes of both n-3 and CLA through the consumption of higher fat grain-fed portions.

Vitamin C supplements and the risk of age-related cataract: a population-based prospective cohort study in women

BACKGROUND

Experimental animal studies have shown adverse effects of high-dose vitamin C supplements on age-related cataract.

OBJECTIVE

We examined whether vitamin C supplements (approximately 1000 mg) and multivitamins containing vitamin C (approximately 60 mg) are associated with the incidence of age-related cataract extraction in a population-based, prospective cohort of women.

DESIGN

Our study included 24,593 women aged 49-83 y from the Swedish Mammography Cohort (follow-up from September 1997 to October 2005). We collected information on dietary supplement use and lifestyle factors with the use of a self-administrated questionnaire. Cataract extraction cases were identified by linkage to the cataract extraction registers in the geographical study area.

RESULTS

During the 8.2 y of follow-up (184,698 person-years), we identified 2497 cataract extraction cases. The multivariable hazard ratio (HR) for vitamin C supplement users compared with that for nonusers was 1.25 (95% CI: 1.05, 1.50). The HR for the duration of >10 y of use before baseline was 1.46 (95% CI: 0.93, 2.31). The HR for the use of multivitamins containing vitamin C was 1.09 (95% CI: 0.94, 1.25). Among women aged > or = 65 y, vitamin C supplement use increased the risk of cataract by 38% (95% CI: 12%, 69%). Vitamin C use among hormone replacement therapy users compared with that among nonusers of supplements or of hormone replacement therapy was associated with a 56% increased risk of cataract (95% CI: 20%, 102%). Vitamin C use among corticosteroid users compared with that among nonusers of supplements and corticosteroids was associated with an HR of 1.97 (95% CI: 1.35, 2.88).

CONCLUSION

Our results indicate that the use of vitamin C supplements may be associated with higher risk of age-related cataract among women.

Associations Between Plasma Levels of Vitamins and Cataract in the Italian-American Clinical Trial of Nutritional Supplements and Age-Related Cataract (CTNS): CTNS Report #2

PURPOSE

To investigate the association at baseline between plasma levels of selected vitamins and the presence and type of cataract in the participants in The Italian-American Trial of Nutritional Supplements and Age-related Cataract.

METHODS

At baseline, the participants (1020, 710 with "early cataract" and 310 with "no cataract," 55-75 years of age) received an ocular examination, photographic lens grading, and measurement of plasma levels of vitamins A, C, E, beta-carotene, and of red blood cell glutathione reductase activity.

RESULTS

In multiple logistic models adjusted for potential confounders, high vitamin C levels were associated with a protective effect on nuclear (N) [OR: 0.54; 95% CI: 0.30, 0.97] and posterior subcapsular (PSC) cataract (OR: 0.37; 95% CI: 0.15, 0.93). High vitamin E levels were associated with increased prevalence of cortical cataract (C) (OR: 1.99; 95% CI: 1.02-3.90), PSC (OR: 3.27; 95% CI: 1.34, 7.96) and of any cataract (OR: 1.86; 95% CI: 1.08, 3.18).

CONCLUSIONS

In agreement with some earlier studies, we found higher plasma levels of vitamin C to be associated with reduced prevalence of N and PSC cataracts. The finding of an increased prevalence of some types of cataract with higher levels of vitamin E was unexpected, has not been previously reported, and could be due to unadjusted confounding.

Antioxidants in Prevention of Cataracts in South India: Methodology and Baseline Data

PURPOSE

To describe the methodology and baseline data for the Antioxidants in Prevention of Cataracts (APC) study in South India.

METHODS

The APC study is a prospective, 5-year, randomized, triple-masked, placebo-controlled, field-based clinical trial to examine the effect of antioxidants (combination tablet of vitamins A, C, and E) on progression of cataract. The primary outcome variable is cataract progression (nuclear opalescence), evaluated with the slit-lamp biomicroscope by the Lens Opacification Classification System III method. Secondary outcome variables are progression in cortical and posterior subcapsular opacity and nuclear color, change in best corrected visual acuity, myopic shift, and treatment failure (progression to cataract surgery or best corrected vision worse than 20/400 in an eye). Inclusion criteria are age between 35 and 50 years and best-corrected visual acuity of 20/40 or better. Exclusion criteria are a diagnosis of diabetes mellitus or nonfasting blood glucose level>7.8 mmol/L, history or presence of various ocular conditions or treatment forms, or current use of vitamin supplements. Baseline ophthalmic, demographic, and potential cataract risk factor data (such as smoking, sunlight, or alcohol exposure) were compared between groups on an intent-to-treat basis.

RESULTS

Of 954 people screened, 798 were enrolled, a sample size which exceeded the required estimate. More than 80% of subjects had 20/20 or better vision in at least one eye, and baseline prevalence of significant cataract according to the LOCS III grading scale was high. The two treatment groups were comparable for all baseline measures except alcohol intake.

CONCLUSION

The sample size and group baseline characteristics will provide sufficient power to detect a change in cataract progression within 5 years.

Evaluation of risk factors for cataract types in a competing risks framework

PURPOSE

In prospective studies of incident cataract, a person may have developed two or all three of cortical, nuclear sclerotic and posterior subscapsular cataract at the time when clinically significant cataract is apparent. One can compare the impact of risk factors on different types of cataract with methods of competing risk survival analysis that account for tied events.

METHODS

We studied risk factors for incident cataract among 20,599 participants in the Physicians' Health Study; 1,923 of whom developed cataract that reduced visual acuity over a median follow-up of 13.0 years. Among incident cases, 45% had two types of cataract and an additional 12% had all three. Proportional hazards models, adjusted for tied failures through use of generalized estimating equations, provided comparisons across different cataract types. Stratified analyses by type with age as the time scale were used to accommodate the strong but different relationships of age with occurrence of different cataract types.

RESULTS

Analyses found different relationships of diabetes and body mass index, but similar relationships of smoking, family history of coronary disease and multivitamin use, across different cataract types. A simplified model provided common estimates for relative risks associated with those characteristics with similar effects across cataract types.

CONCLUSIONS

Whereas polytomous logistic regression has proven useful for comparisons of risks across cataract types in retrospective and cross-sectional studies, this approach based on methods of survival analysis has greater flexibility in prospective studies with variable follow-up and frequently tied event times for different cataract types.

Antioxidant nutrient intake and the long-term incidence of age-related cataract: the Blue Mountains Eye Study

BACKGROUND

Oxidative stress has been implicated in cataractogenesis. Long-term intake of antioxidants may offer protection against cataract.

OBJECTIVE

We investigated relations between antioxidant nutrient intakes measured at baseline and the 10-y incidence of age-related cataract.

DESIGN

During 1992-1994, 3654 persons aged >or=49 y attended baseline examinations of the Blue Mountains Eye Study (82.4% response). Of these persons, 2464 (67.4%) participants were followed >or=1 time after the baseline examinations (at either 5 or 10 y). At each examination, lens photography was performed and questionnaires were administered, including a 145-item semiquantitative food-frequency questionnaire. Antioxidants, including beta-carotene, zinc, and vitamins A, C, and E, were assessed. Cataract was assessed at each examination from lens photographs with the use of the Wisconsin Cataract Grading System. Nuclear cataract was defined for opacity greater than standard 3. Cortical cataract was defined as cortical opacity >or= 5% of the total lens area, and posterior subcapsular (PSC) cataract was defined as the presence of any such opacity.

RESULTS

Participants with the highest quintile of total intake (diet + supplements) of vitamin C had a reduced risk of incident nuclear cataract [adjusted odds ratio (OR): 0.55; 95% CI: 0.36, 0.86]. An above-median intake of combined antioxidants (vitamins C and E, beta-carotene, and zinc) was associated with a reduced risk of incident nuclear cataract (OR: 0.51; 95% CI: 0.34, 0.76). Antioxidant intake was not associated with incident cortical or PSC cataract.

CONCLUSION

Higher intakes of vitamin C or the combined intake of antioxidants had long-term protective associations against development of nuclear cataract in this older population.

A randomized, double-masked, placebo-controlled clinical trial of multivitamin supplementation for age-related lens opacities. Clinical trial of nutritional supplements and age-related cataract report no. 3

OBJECTIVE

To evaluate the effect of a multivitamin/mineral supplement on development or progression of age-related lens opacities.

DESIGN

Randomized, double-masked, single center, placebo-controlled clinical trial.

PARTICIPANTS

One thousand twenty participants, 55 to 75 years old and with early or no cataract, were randomly assigned to a daily tablet of a multivitamin/mineral formulation or a placebo.

METHODS

Baseline and annual lens photographs were graded for severity of lens opacities according to a modification of the Age-Related Eye Disease Study system for classifying cataracts.

MAIN OUTCOME MEASURES

The primary outcome was a prespecified increase from baseline in nuclear, cortical, or posterior subcapsular cataract (PSC) opacity grades or cataract surgery. Secondary outcomes included an increase in type-specific opacity grades, cataract surgery, and visual acuity (VA) loss from baseline > or =15 letters.

RESULTS

Participants were observed for an average of 9.0+/-2.4 years. There was a decrease in total lens events in participants assigned to the multivitamin/mineral formulation compared with those assigned to the placebo (hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.68-0.98; P = 0.03). Nuclear events were significantly less common (HR, 0.66; 95% CI, 0.50-0.88; P = 0.004) and PSC events significantly more common (HR, 2.00; 95% CI, 1.35-2.98; P<0.001) in participants taking the multivitamin/mineral formulation than in those assigned to the placebo. No statistically significant treatment effects were seen for cortical opacities, moderate VA loss, or cataract surgery.

CONCLUSIONS

Lens events were less common in participants who took the multivitamin/mineral formulation, but treatment had opposite effects on the development or progression of nuclear and PSC opacities, the 2 most visually important opacity subtypes.

Associations between age-related nuclear cataract and lutein and zeaxanthin in the diet and serum in the Carotenoids in the Age-Related Eye Disease Study, an Ancillary Study of the Women's Health Initiative

OBJECTIVE

To evaluate associations between nuclear cataract (determined from slitlamp photographs between May 2001 and January 2004) and lutein and zeaxanthin in the diet and serum in patients between 1994 and 1998 and macula between 2001 and 2004.

DESIGN

A total of 1802 women aged 50 to 79 years in Iowa, Wisconsin, and Oregon with intakes of lutein and zeaxanthin above the 78th (high) and below the 28th (low) percentiles in the Women's Health Initiative Observational Study (1994-1998) were recruited 4 to 7 years later (2001-2004) into the Carotenoids in Age-Related Eye Disease Study.

RESULTS

Women in the group with high dietary levels of lutein and zeaxanthin had a 23% lower prevalence of nuclear cataract (age-adjusted odds ratio, 0.77; 95% confidence interval, 0.62-0.96) compared with those with low levels. Multivariable adjustment slightly attenuated the association (odds ratio, 0.81; 95% confidence interval, 0.65-1.01). Women in the highest quintile category of diet or serum levels of lutein and zeaxanthin as compared with those in the lowest quintile category were 32% less likely to have nuclear cataract (multivariable-adjusted odds ratio, 0.68; 95% confidence interval, 0.48-0.97; P for trend = .04; and multivariable-adjusted odds ratio, 0.68; 95% confidence interval, 0.47-0.98; P for trend = .01, respectively). Cross-sectional associations with macular pigment density were inverse but not statistically significant.

CONCLUSIONS

Diets rich in lutein and zeaxanthin are moderately associated with decreased prevalence of nuclear cataract in older women. However, other protective aspects of such diets may in part explain these relationships.

One is okay, more is better? Pharmacological aspects and safe limits of nutritional supplements

The use of vitamins, minerals and other supplements has increased considerably during recent years. In the National Diet and Nutrition Survey of British adults aged 19-64 years 40% of those surveyed were taking supplements. In 2005 sales of dietary supplements in the UK were approximately pound sterling 325.7 x 106 in 'bricks and mortar' shops (excluding health food shops). The physiological effects of vitamins and minerals in amounts approximating to the UK reference nutrient intake or the EU RDA are well understood in terms of reducing the risk of micronutrient deficiency. However, the effects of vitamins, minerals and other supplements in larger amounts have attracted much attention in recent decades, and these effects, some of which may be pharmacological, are not as well categorised. Some of these effects are beneficial, some are not. Although vitamins and minerals and other supplements are generally safe at higher doses, there are some safety issues that are relevant in the context of the wide availability of supplements without a doctor's prescription. Thus, several authorities throughout the world have established upper limits (UL) for the intake of vitamins and minerals, and the EU is in the process of setting maximum permitted levels (MPL) for vitamins and minerals in food supplements. The present paper discusses the potential benefits and safety issues relating to the use of supplements at doses higher than the RDA. The rationale for the establishment of UL is also discussed, explaining the differences between the values set by different authorities and the expected guidance and legislation from the European Commission on MPL for vitamins and minerals in food supplements.

Dietary carotenoids, vitamins C and E, and risk of cataract in women: a prospective study

OBJECTIVE

To examine in prospective data the relation between dietary intake of carotenoids and vitamins C and E and the risk of cataract in women.

DESIGN

Dietary intake was assessed at baseline in 39,876 female health professionals by using a detailed food frequency questionnaire. A total of 35,551 women provided detailed information on antioxidant nutrient intake from food and supplements and were free of a diagnosis of cataract. The main outcome measure was cataract, defined as an incident, age-related lens opacity responsible for a reduction in best-corrected visual acuity in the worse eye to 20/30 or worse based on self-report confirmed by medical record review.

RESULTS

A total of 2031 cases of incident cataract were confirmed during a mean of 10 years of follow-up. Comparing women in the extreme quintiles, the multivariate relative risk of cataract was 0.82 (95% confidence interval, 0.71-0.95; test for trend, P = .04) for lutein/zeaxanthin and 0.86 (95% confidence interval, 0.74-1.00; test for trend, P = .03) for vitamin E from food and supplements.

CONCLUSION

In these prospective observational data from a large cohort of female health professionals, higher dietary intakes of lutein/zeaxanthin and vitamin E from food and supplements were associated with significantly decreased risks of cataract.

The proteasome and intracellular redox status: implications for apoptotic regulation in lens epithelial cells

PURPOSE

This study aimed to investigate redox regulation of the proteasome as well as the effect of proteasome inhibition on intracellular oxidative status and apoptosis.

METHODS

Oxidative stress was induced in cultured human lens epithelial cells (HLECs) and intact mouse lenses by 100 microM H2O2. HLECs were also exposed to the reduced and the oxidized forms of glutathione (GSH/GSSG) and the reducing agent dithiotreitol (DTT). The chymotrypsin-like, the trypsin-like, and the peptidylglutamyl peptidase activities of the proteasome were measured using synthetic fluorogenic substrates. Superoxide as well as peroxide production, mitochondrial membrane potential, and the level of GSH was measured in HLECs after proteasome inhibition by MG-132 or lactacystin. Apoptosis was determined by measuring caspase-3 activation and by studying apoptotic nuclei after staining with Hoechst 33342.

RESULTS

All three peptidase activities of the proteasome were inhibited by 100 microM H2O2 and by the oxidized form of glutathione (GSSG), whereas the reduced form (GSH) stimulated chymotrypsin-like and peptidylglutamyl peptidase activities in HLECs lysates. Intact mouse lenses exposed to 100 microM H2O2 exhibited loss of transparency and trends of decreased chymotrypsin-like proteasome activity as well as decreased GSH levels. Inhibition of the proteasome in cultured HLECs caused significant increase in apoptosis and disturbed intracellular redox balance. Simultaneous addition of exogenous GSH completely abolished the increased apoptosis seen after MG-132 treatment.

CONCLUSIONS

This study supports the hypothesis that intracellular proteolytic and oxidative regulatory systems are tightly coupled. The current data also indicate that apoptosis by proteasome inhibition is mediated through oxidative mechanisms.

Vitamin E and age-related cataract in a randomized trial of women

OBJECTIVE

To investigate whether vitamin E supplementation decreases the risk of age-related cataract in women.

DESIGN

Randomized, double-masked, placebo-controlled trial.

PARTICIPANTS

Thirty-nine thousand eight hundred seventy-six apparently healthy female health professionals aged 45 years or older.

INTERVENTION

Participants were assigned randomly to receive either 600 IU natural-source vitamin E on alternate days or placebo and were followed up for presence of cataract for an average of 9.7 years.

MAIN OUTCOME MEASURE

Age-related cataract defined as an incident, age-related lens opacity, responsible for a reduction in best-corrected visual acuity to 20/30 or worse, based on self-report and confirmed by medical record review.

RESULTS

There was no significant difference between the vitamin E and placebo groups in the incidence of cataract (1159 vs. 1217 cases; relative risk [RR], 0.96; 95% confidence interval [CI], 0.88-1.04). In subgroup analyses of subtypes, there were no significant effects of vitamin E on the incidence of nuclear (1056 vs. 1127 cases; RR, 0.94; 95% CI, 0.87-1.02), cortical (426 vs. 461 cases; RR, 0.93; 95% CI, 0.81-1.06), or posterior subcapsular cataract (357 vs. 359 cases; RR, 1.00; 95% CI, 0.86-1.16). Results were similar for extraction of cataract and subtypes. There was no modification of the lack of effect of vitamin E on cataract by baseline categories of age, cigarette smoking, multivitamin use, or several other possible risk factors for cataract.

CONCLUSIONS

These data from a large trial of apparently healthy female health professionals with 9.7 years of treatment and follow-up indicate that 600 IU natural-source vitamin E taken every other day provides no benefit for age-related cataract or subtypes.

Changes in plasma antioxidant status following consumption of diets high or low in fruit and vegetables or following dietary supplementation with an antioxidant mixture

The aim of the present study was to examine the effect of consumption of a high-fruit and vegetable diet, or a spray-dried extract of selected fruits and vegetables of high antioxidant content, on indices of antioxidant status of individuals consuming a background diet with minimal antioxidant intake. Plasma antioxidant concentrations were determined in twenty-five men following a 2-week depletion period during which they consumed self-selected low-antioxidant diets (less than three servings of fruit and vegetables with no tea, coffee, red wine or fruit juice). Following this period the volunteers consumed either a self-selected diet containing five to seven servings of fruit and vegetables/d, or 30 g of a spray-dried supplement designed to provide the equivalent antioxidant activity of five to seven servings of fruit and vegetables for 2 weeks in a crossover trial. Following consumption of a high-antioxidant diet for 2 weeks, plasma concentrations of ascorbic acid, α- and β-carotene and lutein+zeaxanthin were all significantly increased (P<0.05) over the depletion period. However, concentrations of lycopene, retinol and tocopherol were not affected. Consumption of the supplement also raised the concentrations of these same antioxidants in plasma. Despite the increases in the concentrations of measured antioxidant nutrients, the 6-hydroxy-2,5,7,8-tetramethylchroman-2-carboxylic acid-equivalent antioxidant capacity of plasma, as estimated by inhibition of metmyoglobin activity, was not significantly affected by any of the dietary treatments.

Multivitamin-multimineral supplements and eye disease: age-related macular degeneration and cataract

The prevalence and effects of age-related macular degeneration (AMD) and cataract are increasing dramatically as the proportion of elderly in our population continues to rise. A multivitamin-multimineral supplement with a combination of vitamin C, vitamin E, beta-carotene, and zinc (with cupric oxide) is recommended for AMD but not cataract. Weak support exists for multivitamins or other vitamin supplements from observational studies of cataract. The results of observational studies suggest that a healthy lifestyle with a diet containing foods rich in antioxidants, particularly lutein and zeaxanthin, as well as n-3 fatty acids, appears beneficial for AMD and possibly cataract. The Age-Related Eye Disease Study II will evaluate some of these additional nutrients as dietary supplements in a randomized trial.

Oxidation, antioxidants and cataract formation: a literature review

PURPOSE

This review aims to provide a literature survey of the association between photo-oxidation of lens proteins and lipid peroxidation with the genesis of age-related cataract in laboratory studies using rodent models, in epidemiological and interventional studies in humans.

MATERIALS AND METHODS

A Medline search using initial search terms lens, oxidation, antioxidant, and diet was employed to search for research papers covering the areas noted above from 1995 to 2005. Literature cited in those papers was also reviewed to provide as comprehensive a coverage of research work as possible.

RESULTS

Lens protein photo-oxidation and lipid peroxidation are widely acknowledged as important steps in age-related cataractogenesis. Dietary antioxidants are central in retarding cataractogenesis, although most evidence for this is gained from laboratory-based work on relatively unphysiologic rodent cataract models, using antioxidant regimes that could not be sustained in clinical practice. Most research in humans is retrospective epidemiology although some interventional research has been undertaken, with mixed results.

CONCLUSIONS

Dietary antioxidants are likely to be important in retarding cataractogenesis in older animals and in humans. Work on companion animals could provide a valuable stepping stone between rodent-based laboratory work and human interventional studies.

Centrum use and progression of age-related cataract in the Age-Related Eye Disease Study: a propensity score approach. AREDS report No. 21

PURPOSE

To evaluate the effect of the multivitamin Centrum on the development and progression of age-related lens opacities.

DESIGN

Clinic-based prospective cohort study.

PARTICIPANTS

Four thousand five hundred ninety individuals with at least one natural lens and photographic follow-up (median, 6.3 years) were assessed for development or progression of lens opacities.

MAIN OUTCOME MEASURES

Progression of "any" lens opacity or type-specific opacity was ascertained from lens photographs taken at baseline and at annual visits beginning at year 2.

METHODS

The Age-Related Eye Disease Study (AREDS) showed no statistically significant effect of a high-dose antioxidant formulation on progression of lens opacities. Centrum also was provided to approximately two thirds of the study participants. Because Centrum use was elective, a logistic regression model of baseline characteristics was used to generate a propensity score for Centrum use. Repeated-measures logistic regression, adjusted for propensity score and other covariates, was used to evaluate associations of Centrum use and lens opacity.

RESULTS

Centrum use, adjusted for propensity score and other covariates, was associated with a reduction in "any" lens opacity progression (odds ratio [OR] = 0.84, 95% confidence interval [CI] = 0.72-0.98, P = 0.025). Results for individual lens opacity types suggested that Centrum use was protective for nuclear opacity events (OR = 0.75, 95% CI = 0.61-0.91, P = 0.004).

CONCLUSION

Observational data from the AREDS and other studies suggest that use of a multivitamin may delay the progression of lens opacities. A National Eye Institute-sponsored clinical trial scheduled for completion in 2007 will provide additional data on Centrum use and cataract development.

Oxidative stress in cataracts

Oxidative stress is the result of an imbalance of antioxidants and pro-oxidants. Since toxic free radicals are the result of normal metabolism, their destruction is imperative. Cataracts are the leading cause of blindness worldwide. Opacity of the lens is a direct result of oxidative stress. Cataracts occur primarily due to age, but also are common in diabetes where superoxide in the mitochondria is elevated as a result of hyperglycemia. This review will investigate the risk factors of cataract including diet (vitamins, fat and alcohol) as well as UV light and diabetes. The pathophysiology of lens opacification will be discussed and related to the biochemistry, especially during the aging process and in diabetes. Animal and human supplemental antioxidant studies will be reviewed and the mechanisms discussed for cataract prevention and treatment. New genetic engineering approaches to overexpress antioxidant enzymes have given intriguing results and show promise. Lastly, a new approach to target mitochondrial superoxide with antioxidant molecules will be outlined.

Nutritional antioxidants and age-related cataract and maculopathy

Loss of vision is the second greatest, next to death, fear among the elderly. Age-related cataract (ARC) and maculopathy (ARM) are two major causes of blindness worldwide. There are several important reasons to study relationships between risk for ARC/ARM and nutrition: (1) because it is likely that the same nutritional practices that are associated with prolonged eye function will also be associated with delayed age-related compromises to other organs, and perhaps, aging in general, (2) surgical resources are insufficient to provide economic and safe surgeries for cataract and do not provide a cure for ARM, and (3) there will be considerable financial savings and improvements in quality of life if health rather than old age is extended, particularly given the rapidly growing elderly segment of our population. It is clear that oxidative stress is associated with compromises to the lens and retina. Recent literature indicates that antioxidants may ameliorate the risk for ARC and ARM. Given the association between oxidative damage and age-related eye debilities, it is not surprising that over 70 studies have attempted to relate antioxidant intake to risk for ARC and ARM. This article will review epidemiological literature about ARC and ARM with emphasis on roles for vitamins C and E and carotenoids. Since glycation and glycoxidation are major molecular insults which involve an oxidative stress component, we also review new literature that relates dietary carbohydrate intake to risk for ARC and ARM. To evaluate dietary effects as a whole, several studies have tried to relate dietary patterns to risk for ARC. We will also give some attention to this emerging research. While data from the observational studies generally support a protective role for antioxidants in foods or supplements, results from intervention trials are less encouraging with respect to limiting risk for ARC/ARM prevalence or progress through antioxidant supplementations, or maintaining higher levels of antioxidants either in diet or blood. Without more information it is difficult to parse these results. It would be worthwhile to determine why the various types of studies are not yielding similar results. However, there are many common insults and mechanistic compromises that are associated with aging, and proper nutrition early in life may address some of these compromises and provide for extended youthful function later in life. Indeed, proper nutrition, possibly including use of antioxidant supplements for the nutritionally impoverished, along with healthy life styles may provide the least costly and most practical means to delay ARC and ARM. Further studies should be devoted to identifying the most effective strategy to prevent or delay the development and progress of ARC/ARM. The efforts should include identifying the right nutrient(s), defining useful levels of the nutrient(s), and determining the age when the supplementation should begin.

The Antioxidants in Prevention of Cataracts Study: effects of antioxidant supplements on cataract progression in South India

AIM

To determine if antioxidant supplements (beta carotene and vitamins C and E) can decrease the progression of cataract in rural South India.

METHODS

The Antioxidants in Prevention of Cataracts (APC) Study was a 5 year, randomised, triple masked, placebo controlled, field based clinical trial to assess the ability of interventional antioxidant supplements to slow cataract progression. The primary outcome variable was change in nuclear opalescence over time. Secondary outcome variables were cortical and posterior subcapsular opacities and nuclear colour changes; best corrected visual acuity change; myopic shift; and failure of treatment. Annual examinations were performed for each subject by three examiners, in a masked fashion. Multivariate modelling using a general estimating equation was used for analysis of results, correcting for multiple measurements over time.

RESULTS

Initial enrolment was 798 subjects. Treatment groups were comparable at baseline. There was high compliance with follow up and study medications. There was progression in cataracts. There was no significant difference between placebo and active treatment groups for either the primary or secondary outcome variables.

CONCLUSION

Antioxidant supplementation with beta carotene, vitamins C and E did not affect cataract progression in a population with a high prevalence of cataract whose diet is generally deficient in antioxidants.

Evidence for the use of nutritional supplements and herbal medicines in common eye diseases

PURPOSE

To provide a perspective by reviewing the evidence for the role of nutritional supplements and herbal medicines in the common causes of visual impairment.

DESIGN

Retrospective literature review.

METHODS

Published studies and information found in PubMed, International Bibliographic Information of Dietary Supplements, and selected websites were reviewed for the role of nutritional and herbal medicines in the treatment of age-related macular degeneration, cataract, diabetic retinopathy, and glaucoma. The studies were evaluated systematically for their study design, study population, benefits, risks, biases, and criteria for the categorization of the level of evidence.

RESULTS

The available evidence does support the use of certain vitamins and minerals in patients with certain forms of age-related macular degeneration. For cataracts, the available evidence does not support these supplements to prevent or treat cataracts in healthy individuals. For diabetic retinopathy and glaucoma, the available evidence does not support the use of these supplements. In the category of herbal medicines, the available evidence does not support the use of herbal medicines for any of these ocular diseases.

CONCLUSION

Because of the widespread use of nutritional supplements and herbal medicines, ophthalmologists should be aware of their use so that they can inform patients properly when the supplements and herbal medicine are being used for eye disease.

Dietary modulation of lens zeaxanthin in quail

Although higher dietary intake of lutein/zeaxanthin has been associated with reduced risk for cataracts, the impact of dietary supplements on lens lutein (L) or zeaxanthin (Z) has not been examined. If higher lens carotenoids do reduce risk for cataract, it would be essential to know whether dietary carotenoids can elevate carotenoids in the adult vertebrate lens. In this study, a covey of Japanese quail were hatched and raised 6 months on carotenoid-deficient diet, then switched to deficient diet supplemented with low or high 3R,3R'-zeaxanthin (5 or 35 mgkg(-1) food) or beta-carotene (50 mgkg(-1) food). Controls included a group of covey-mates that remained on the deficient diet and another raised from birth on the high Z (35 mg Zkg(-1)) diet. At 1 year of age, carotenoids and tocopherols in the lens and in the serum were analysed by HPLC, and compared by analysis of variance. Serum Z was significantly elevated in deficient birds fed the lower or higher Z supplement for 6 months (P<0.0001 for each). Serum Z in birds maintained on the higher Z supplement for 1 year was much higher than that in deficient birds (P<0.0001), but not different from deficient birds given the higher Z supplement. As in humans, the predominant lens carotenoids were lutein (L) and zeaxanthin (Z), and the total carotenoid concentration was of lower magnitude than the concentration of alpha-tocopherol. Responses to Z supplementation were sex-related. Female quail had 5-10 times higher serum concentrations of both Z and L than males (P<0.0001, <0.001), and they also had higher lens Z concentrations than males (P<0.0006); possible effects of estrogen on lens carotenoids are discussed. Lens Z concentration was strongly and positively correlated with serum Z in females (r=0.77; P<0.002). Deficient adult females supplemented with the 35 mgkg(-1) dose of Z for 6 months had a mean lens Z concentration (0.252+/-0.06 microgg(-1) protein) close to that in females fed with the supplement from birth (0.282+/-0.15 microgg(-1) protein). Birds fed with the higher dietary Z supplement for 6 or 12 months had significantly higher lens Z than birds fed lower or no dietary Z (P<0.0001). Lens L was not altered by dietary supplementation with either Z or beta-carotene. beta-Carotene supplements did not result in detectable lens beta-carotene, and had no effect on lens Z. Neither Z nor beta-carotene supplementation had a significant effect on serum or lens tocopherol concentrations. These studies in quail provide the first experimental evidence that lens carotenoids in adult vertebrates can be manipulated by dietary Z supplements.

Oxidative modification of rat eye lens proteins by peroxyl radicals in vitro: protection by the chain-breaking antioxidants stobadine and Trolox

In an attempt to model the processes of free radical-mediated cataractogenesis, we investigated the oxidative modification of rat eye lens proteins by peroxyl radicals generated by thermal decomposition of 2,2'-azobis(2-amidinopropane)hydrochloride (AAPH) under aerobic conditions. When incubated with AAPH, the soluble eye lens proteins precipitated in a time-dependent manner. The insolubilisation was accompanied by the accumulation of protein free carbonyls and the diminution of sulfhydryls, yet the processes were shifted in time. The SDS-PAGE analysis of the AAPH-treated proteins revealed the presence of high molecular weight cross-links and, to a lesser extent, fragments. The aggregation and cross-linking of proteins along with the generation of free carbonyls was significantly inhibited by the chain-breaking antioxidants stobadine and Trolox. On the other hand, the AAPH-initiated sulfhydryl consumption was much less sensitive to the antioxidants studied. The results point to a complex mechanism of peroxyl-radical-mediated modification of eye lens proteins with implications for cataract development and they indicate a potentially protective role of antioxidants.