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Solutions for Macular Degeneration

I imagine you already know one or more people dealing with macular degeneration. The good news is that doctors can “deal with” the problem once it arises; the bad news is that treatment can slow the progression of the disease, but is not a cure. Macular degeneration is ultimately the leading cause of vision loss in adults aged 65 and older, affecting more than 10 million folks in the US. The age association is part of the disease name: AMD, or age-related macular degeneration.

The macula is the most important part of your visual retina: just off center, it is the area where you have your sharpest visual acuity. It’s the part of your eye that relays the image when you are looking directly at something of interest. 

What Is Known About Macular Degeneration

The macula can degenerate in either one of two opposite ways. In the most common, atrophic or ‘dry’ form of macular degeneration, the vitality of the retina actually deteriorates, the tissue undergoes a kind of fading and death. In the ‘wet’ form, abundant new blood vessels form in a process called ‘neovascularization’, which is a process the body uses to create new blood circulation. Neovascularization is very helpful if you’re developing new function in an area new to a region of disability, such as new circulation to heart muscle after one area has been damaged. It is also the process the body uses to fuel completely new growth, such as cancerous tissues! Definitely a mixed bag, in general. In the macula, new blood vessels can lead to swelling, hemorrhage and eventually retinal detachment and loss of vision.

Conventional understanding of macular degeneration documents a few risk factors that can be modulated to support macular health. Known risk factors include advanced age (risk starts increasing after the age of 50 or 55), smoking, high BMI (I believe it’s obesity, not high BMI itself), excessive exposure to ultraviolet light, and lack of proper dietary nutrients. It is often referred to as AMD, or age-related macular degeneration.

Of all of the known risk factors, advanced age (that’s a good thing!) and smoking (you can control this, really, you can) are the most important risk factors. We welcome advanced age, so it’s important to tease out the remaining risk factors.

Additional interesting associations have been observed, possibly leading to a broader understanding of the disease. Macular degeneration is itself a risk factor for stroke and coronary artery disease, quite separate from risk factors shared by the two diseases. By that I mean that non-smoking folks with macular degeneration have a higher heart disease risk than non-smokers without macular degeneration. So what else could be going on?

Some researchers have noted that individuals with macular degeneration have lower levels of the adrenal hormone DHEA than folks with healthy retinas. As a part of the brain, we might expect the retina to depend on healthy levels of not just DHEA, but all the crucial neuro-protective hormones, such as estradiol, testosterone, pregnenolone, and melatonin. Studies are underway to determine if the proposed benefit from hormones extends from the brain to the retina. 

The long-term Age-Related Eye Disease Study (AREDS) found that supplemental anti-oxidants reduce the risk of AMD, and has led to numerous anti-oxidant combo’s recommended by opthalmologists. I’ll make some more specific recommendations based on optimal versions of those same nutrients. Anti-oxidants’ role in the retina might be related to the level of lipids in the blood, and specifically the amount of oxidized apoB100 lipoproteins: high levels are associated with both cardiovascular disease and AMD, and improved anti-oxidant capacity might lower that risk.

Total amounts of serum lipids have not been found to be consistently associated with AMD. There have been some suggestions that elevated total cholesterol and even elevated HDL (so-called “good” cholesterol) might increase the risks of AMD, particularly the ‘wet’ kind. The issue is unresolved: there are clearly lipoproteins in the retina of patients with AMD, but it is not clear if they derive from the liver and circulation or whether they are produced locally by the retina in response to injury or as part of some unknown process. Furthermore, studies of the association between statins and AMD have been contradictory, with little clear problematic nor beneficial relationship.

Interestingly, the search for genetic associations which might explain the familial tendency of AMD have found a surprising association. The ApoE gene has gained prominence recently because of its association with cardiovascular disease and dementia. The ApoE3 form is the “normal” or predominant version of the gene. ApoE4 status raises your risk for both heart disease and dementia…but lowers your risk of AMD. Conversely, the heart and brain protective ApoE2 version seems to raise your risk of AMD. No free lunch, as they say?

Epidemiological observations show an association with high homocysteine levels and the development of AMD. In a randomized, double-blind controlled trial, the group that received supplementation with just moderate levels of the worst forms of the relevant B vitamins (folic acid for B9 2.5 mg/day, pyridoxine HCl for B6 50 mg/day and cyanocobalamin for B12 at 1 mg/day) had 41% less AMD over the 7.3 years of the study compared to the non-supplemented group.   

Impaired visual acuity from any cause has been observed to correlate with a greater tendency to develop dementia And although controversial, recent studies suggest that AMD, especially dry AMD is independently associated with an increased risk of developing subsequent AD or senile dementia. Both conditions share common risk factors, so the association is not mysterious, but it is also true that patients with pre-existing dementia might be less likely to be pro-active OR identified and treated for macular degeneration.

If you are interested in learning more about macular degeneration, the best (and most accessible) review article I’ve found is  Lipids, Lipoproteins, and Age-related Macular Degeneration by Ebrahimi and Handa, available online in the Journal of Lipids.

 

Healthy Steps: Macular Degeneration—First Steps

For the greatest health improvement with the fewest steps, do the following:

  • Eat wild-caught salmon or other omega-3-rich fish at least once a week.
  • Eat abundant amounts of brightly colored vegetables, especially those that are red, yellow and green, accompanied by leafy greens.
  • If you smoke, stop smoking.

Healthy Steps: Macular Degeneration—Full Program

A comprehensive program involves many areas in which action steps can be taken, gradually or all at once. 

Choose Helpful Foods

Protein: Eat to satiety and always accompany with healthy fat to enhance nutrient absorption. Since many people cannot efficiently convert the carotenes in plants to true vitamin A, vegetables are not a reliable source of vitamin A. You must instead obtain it from animal proteins. Seafood should be wild-caught; meat should be free-range and grass-fed or wild; and poultry should be free-range or pastured.

  • Seafood: Emphasize omega-3-rich varieties such as wild Alaskan salmon and salmon roe (avoid farmed), herring, anchovies, sardines, and halibut. Another excellent choice would be zinc-rich oysters, any way you like them.
  • Eggs: Consume eggs from pastured hens whenever possible. Eat as many eggs as desired, at least 2-3 yolks daily.
  • Organ meats: Eat once a week. If you have never enjoyed liver, try one of the chicken liver recipes here or here. Once you find it easy to eat chicken liver, you can move on to beef liver. The secret to palatability is to marinate it in lemon juice before cooking and to avoid over-cooking the liver. Bacon and onions go well with liver, and ketchup (low sugar please) actually adds valuable nutrients for your eyes! See our Recipe section for chicken liver recipes.

Fat: Essential for nutrient absorption, adequate fat also provides satiety in a carbohydrate-cautious diet. Restricting fat is hazardous causes fat-soluble vitamins to be lost and protein content to increase to dangerous levels for the kidneys.

  • Animal fats: Butter, fatty cuts of meat, poultry skin, and fat reserved from roasting meats provide valuable sources of fuel and fat-soluble vitamins. Use fats only from grass-fed meats.
  • Vegetable fats: Choose organic fats to avoid oil-soluble residues of chemicals or hormones. Healthy choices include coconut oil, coconut milk, extra virgin unrefined olive oil, and, for flavor, small amounts of sesame oil or other nut oils. For sautéing, maintain low temperatures and use fats that are solid at room temperature such as coconut oil, butter, ghee, and animal fat.
  • Avocado: Half an avocado daily provides a tasty fat and a valuable source of healthful fatty acids and nutrients.
  • Olives: Extra virgin olive oil and olives (up to 4 daily) contain important trace minerals. Olive oil should be raw and unheated and never used for cooking.
  • Nuts: The healthiest choices for eye health are pumpkin seeds. Copper levels can be high in nuts and seeds, but pumpkin seeds are a good snack choice, as they have a healthy amount of zinc, so that zinc still can predominate over copper in your diet. 

Vegetables and fruits: Vegetables provide valuable nutrients linked to the actual color of the food itself, with less inflammatory sugar than fruits. All choices of vegetables and fruits are more nutritious if the color pervades the fruit: a plum has more nutrients than an apple when it comes to the color-coded nutrients. Choose a bountiful array of foods:

  • Yellow from yellow peppers, squash, golden beets and tomatoes, with a tiny nod to the grain, corn. Yellow fruits include golden kiwifruit, grapefruit, lemon and yellow-on-white apples and bananas.
  • Red from vegetables such as red peppers, tomatoes, cabbage, radicchio lettuce, red onions, and also the red-on-white potatoes and radishes. Red fruits include cranberries, cherries, blood oranges, pink grapefruit, pomegranates, rhubarbs and grapes. Red-on-white fruits such as apples and pears and strawberries are quite far down the list! 
  • Vegetables such as orange peppers, carrots, squash (pumpkins!), rutabaga, sweet potatoes, and fruits like apricots, cantaloupe, mangoes, nectarines, oranges, peaches, tangerines, and papaya.
  • Last, but not least, find ways to eat leafy greens at least twice a day: added to omelets, salads (breakfast, lunch and dinner salads might all look a little different), steamed greens, or greens blended into soup, salad dressings, meat sauces, or pesto

Avoid Problematic Foods

Avoid foods likely to raise the general levels of inflammation in your body.

  • Avoid foods to which you are allergic. If you suspect allergies, but are not sure, consult the article on the Allergy Elimination Diet.
  • Excessive sugars: Small amounts of sweets, as part of a meal, can be tolerated, but check with your doctor if you are concerned that your sugar levels are too high, and thus inflammatory.
  • Grains: All grain products (including whole and sprouted grains) are potentially problematic, including wheat, rye, barley, spelt, corn, rice, kamut, oats, triticale, and beer. Highly processed quick-cooking grains such as instant rice and ready-to-eat breakfast cereals should be permanently avoided. Small amounts of carefully prepared grains may be tolerated.
  • Vegetable oils and GMO oils: Genetically modified oils include canola, corn, soy, and cottonseed. Also avoid sunflower and safflower oils, margarine, and all trans fats. All these oils increase general levels of inflammation and raise your risk of varied diseases, from macular degeneration to certain cancers. 
  • Harshly fried foods: Unstable oils are the worst, but even using good oils, foods can be fried too harshly: anytime you have a tasty brown fried crust on a food, it can act as an agent of inflammation.

Vital Supplements

Based on the AREDS (National Eye Institute) study, my recommendation is to find a good multi-vitamin such as Thorne Basic Nutrients III, and take 4-6 a day as required to obtain:

  • ​500 mg of vitamin C
  • 400 IU of vitamin E
  • zinc 30 mg a day, copper not required in the vitamin
  • Vitamin A to include beta-carotene as well as retinol. Vitamin A is a fat-soluble vitamin particularly important for eye health. Although beta-carotene is a precursor to vitamin A, not all bodies are able to transform it successfully, so some pure A (retinol) in the vitamin is helpful as well as getting it from food: butter, liver, egg yolks or fish liver oils.

Vitamin D: Obtain vitamin D from the sun with 20 minutes of full-body (not just hands and ankles) exposure to midday sun (May to September in northern latitudes). With direct UV exposure, the body can generate up to 20,000 units or more of vitamin D daily. Test your blood level of vitamin D3: the ideal range for healthy people is 40-65 ng/ml; those with health challenges may benefit from higher levels. If sun exposure is not giving you adequate vitamin D3 levels, take Pure Encapsulations Vitamin D3. Take as needed to normalize blood levels. For most adults that amount is approximately 4000 i.u., daily, or consult your health care professional for individual requirements

Appropriate supplements to normalize homocysteine in a physiological manner, likely including:

  • ​Methyl folate or folinic acid, 1-15 mg daily. (Avoid folic acid.)
  • Pyridoxal-5-phosphate, approximately 25-50 mg daily
  • Methyl-, hydroxy-, or adenosyl-cobalamin, 1-5 mg daily. (Avoid cyanocobalamin.)
  • For those intolerant of methylated vitamins, phosphatidyl choline, 900 mg, 1-2 times daily, may be helpful.

Lifestyle

Don't smoke!

If you are at risk for macular degeneration, you want a good partnership with your primary physician as well as an opthalmologist.

  • Check blood levels of homocysteine (goal 5-8 mmol/L), vitamin D (40-65 ng/mL)
  • Have your eyes checked starting at the age of 40, increasing to exams every 1-2 years after the age of 50.

Exercise helps your eyes, too! Research suggests that one hour a day of moderate exercise can protect the eyes of susceptible mice from the type of degeneration that correlates with age-related macular degeneration in humans. Considering the importance of overall health, I would encourage you first to find a form of actually challenging exercise (more than walking around the block) that you actually enjoy and indulging your passion several times a week. We can all benefit from greater activity (standing over sitting, walking over standing) and some occasional strenuous bursts of exertion and lifting heavy objects.

Protect your eyes. When you're outside, it can be beneficial to have 15-30 minutes of unfiltered exposure to blue sky and sunlight, but when you are out for a prolonged period of time, or the light is very bright, wearing sunglasses to protect your eyes from excessive exposure to UV (ultraviolet) and HEV (high intensity visible) light can reduce your risk of macular degeneration.https://www.allaboutvision.com/conditions/amd-prevention.htm

 

Prevention

There is no doubt that when it comes to macular degeneration, the emphasis is on prevention rather than treatment, as there is to date no cure for macular degeneration. All of the methods mentioned above, all the lifestyle measures, can help reduce your risk of developing macular degeneration, as well as help to reduce the rate of progression and severity of the disease. .

 

 

 

This information is provided for educational purposes only, and any individual diagnosis or treatment should be determined by you and your doctor. See Additional Information.

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