Eye Health Protocol From the Emerson Ecologics Medical Education Team

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Understanding Areds Trials and Applications for Eye Health

We often take our eyes for granted, but we should all be concerned with taking care of them. Although regular eye exams are important for everyone, most people don’t think about eye health unless eye disease runs in the family. 

Aging, sun exposure, lengthy screen time, and certain medical conditions can all affect eyesight. While some vision changes are a normal part of aging, there are several things you can do to protect your eyesight. These are all listed below, and provided as a handout with the protocol. But first, let’s review the history and relevance of current recommendations for eye health supplementation.

The Age-Related Eye Disease Studies (AREDS) Insights

Research on preventing or reversing age related eye disease (ARED) made the news way back in the 1990s with the first Age-Related Eye Disease Study (AREDS) trial. AREDS was a major clinical trial sponsored by the National Eye Institute to learn more about the history of, and risk factors for, age-related macular degeneration (AMD) and cataract. At this point, researchers had determined that oxidative damage over time plays a role in progressive age-related eye disease. AREDS was designed to determine if daily intake of certain antioxidant vitamins and minerals could reduce the risk of cataract and AMD or perhaps delay the onset or progression. Keep in mind there were two successive trials, called AREDS and AREDS2.

Results from the first AREDS trial, which were reported in October 2001, indicated that five years of supplementation with high doses of antioxidant vitamins, copper, and zinc reduced the risk of developing advanced AMD in 30% of individuals in the study who had already-existing moderate to advanced AMD. There was seemingly no effect on cataract.

However, AREDS2 participants with the lowest level of dietary lutein and zeaxanthin, measured at enrollment, who took supplements had on average a 32% reduction in progression to cataract surgery.

The AREDS/AREDS2 trials suggest that supplements may not prevent AMD but may delay progression and help maintain vision longer. The participants of the AREDS trial have now been followed for more than 10 years, and the benefits of the AREDS formulation have persisted over this time.

The AREDS and AREDS2 formulas do not substitute for multivitamins. In both trials, most of the participants took multivitamins. But, taking an AREDS formulation provided a benefit over and above multivitamins.

Why are the AREDS and AREDS2 formulas different?

The first AREDS formula reduced the risk of advanced AMD by about 25% over a five-year period. In the AREDS2 trial, adding omega-3s or lutein + zeaxanthin to the AREDS formulation (containing beta-carotene) had no additional overall effect on the risk of advanced AMD. However, trial participants who took AREDS2 formula containing lutein + zeaxanthin and no beta-carotene had a reduction in risk of advanced AMD, compared with those who took AREDS with beta-carotene. Additionally, former smokers who took AREDS with beta-carotene had a higher incidence of lung cancer. Therefore, the AREDS2 formula eliminated beta-carotene, and added lutein and zeaxanthin in its place. That is the only difference in the two formulas now.

AREDS and AREDS2 components

Lutein, zeaxanthin, and beta-carotene

Lutein, zeaxanthin, and beta-carotene are all carotenoids. Our bodies convert beta-carotene from plant foods to vitamin A, which is required by the retina to detect light and convert it into electrical signals. Beta-carotene itself is not found in the eye. In contrast, lutein and zeaxanthin are found in the retina and lens, where they may act as natural antioxidants and help absorb high-energy blue and ultraviolet light. That appears to be their purpose.

Analysis from the AREDS2 trial suggests that lutein + zeaxanthin offers similar or better benefits compared with beta-carotene.

Zinc

In the AREDS trial, the 80 mg zinc dose (alone or in combination with antioxidant vitamins) was found to be effective compared to a placebo. Researchers chose this extreme dose, to overcome dietary interference with bioavailability and absorption. Although zinc was found to be an essential component of the AREDS formulation, nutritional experts recommended a lower dose. In the AREDS2 trial participants were given the option to take the original formula or to be randomly assigned to receive a modified version, such as a formula containing 25 mg zinc. The investigators did not find a difference in the effects of 80 mg vs. 25 mg zinc. However, because AREDS2 did not include a placebo control, results from AREDS, a placebo-controlled trial, are still considered the standard. But, given the success of the formula with only 25 mg zinc, I’m sure integrative practitioners can extrapolate that 80 mg of zinc daily is likely unnecessary and risky compared to 25 mg which also showed benefit.

Vitamin E

The AREDS formula contains 400 IU to provide vitamin E beyond usual dietary intake. The AREDS and AREDS2 trials found no adverse effects of 400 IU/day vitamin E. However, due to results of studies on vitamin E, there was concern that the high dose vitamin E may increase risk of prostate cancer. AREDS/AREDS2 found no effect of high-dose vitamin E on prostate cancer risk. However, data from other studies on the relationship between vitamin E and prostate cancer conflict and controversy exists:

• In 1994, the Alpha-Tocopherol, Beta Carotene (ATBC) trial found a 35% reduced risk of prostate cancer in men taking 50 mg of vitamin E (synthetic, equivalent to 56 IU) daily for a follow-up of six years.
• In 2009, the Physicians Health Study II (PHS II) found that 400 IU of vitamin E every other day for a follow-up of eight years had no effect on the incidence of prostate cancer.
• In 2011, the Selenium and Vitamin E Cancer Prevention Trial (SELECT) found a 17% increase in prostate cancer risk among men taking 400 IU of vitamin E daily for a follow-up of seven years, but men who took both vitamin E and selenium did not have an increased rate of prostate cancer.

Will the AREDS/AREDS2 formulations help prevent cataract formation?

AREDS was designed to determine if daily intake of certain vitamins and minerals could reduce the risk of cataract formation and AMD but there was no effect on cataract formation in that first trial. However, AREDS2 participants with the lowest level of dietary lutein and zeaxanthin, measured at enrollment, who took a formulation including those nutrients had on average a 32% reduction in progression to cataract surgery.

Clinical Take-aways:

Of the two formulations, the AREDS2 formula with lutein and zeaxanthin, was more effective overall, and safer for smokers. There is still a question as to whether the high recommendations for vitamin E and zinc are actually necessary, and lower doses may be both prudent and effective, especially for at-risk patient populations. 

It’s also important to note, the original AREDS trial involved 4,757 participants, ages 55-80 at the time of enrollment. Of 4,203 surviving participants, 3,549 (about 84%) took part in the follow-on AREDS2 trial. From a logical standpoint, waiting until age 55-80 to begin lifestyle and supplement interventions may just be a little too late to prevent eye disease that is already developing. On the flip-side, those who start early supplementation at younger ages may require lower daily doses of antioxidants for the same benefit.

Lifestyle Recommendations for Better Eye Health

Aside from the importance of a daily multivitamin containing adequate zinc, vitamin E, selenium, lutein and zeaxanthin specifically to support eye health, the following steps should also be incorporated into daily living:

1. Annual Eye Exams

First and foremost, get yearly eye exams. Even if you don’t wear contacts or glasses, an eye exam with dilation is sometimes the only way to identify eye disease in its early stages.

2. Take Breaks from Screens

Have you heard of the 20-20-20 rule? The American Academy of Ophthalmology recommends the 20-20-20 rule. Every 20 minutes you’re looking at a screen, look at something about 20 feet away for 20 seconds. This allows your eyes to relax and focus on something besides the screen.

3. Don’t Smoke

Smoking increases your chances of developing certain eye diseases such as glaucoma, cataracts, and age-related macular degeneration. Smokers also often experience dry eyes. When your eyes aren’t properly lubricated, they’re more easily irritated and more susceptible to injury.

4. Wear Protective Sunglasses

UV rays damage our eyes. Excessive sun exposure increases your chances of developing cataracts and eye cancer. So, wear sunglasses year-round. Many people only wear sunglasses when it’s sunny out, but UV rays shine through clouds on overcast days, too. Choose sunglasses with adequate UV protection. If you spend a lot of time outdoors, a wide-brimmed hat will also help shield your eyes from the sun.

5. Stay Well Hydrated

When we don’t drink enough water, our eyes get dry and scratchy. Many of us already deal with some dry eye from our amount of screen use and chronic dry eye increases the risk of cornea injury, so don’t ignore dry eyes and use natural eye drops as needed.

6. Get Adequate Sleep

Tired eyes have trouble focusing. It’s only when we’re sleeping that they get a chance to rest and rehydrate.

7. Stick to An Exercise Routine

Exercise is good for circulation. If any particular eye diseases run in your family, exercise is even more important for your eye health.

8. Eat an Eye-Healthy Diet

Research suggests that people who have diets rich in green, leafy vegetables—a good source of lutein and zeaxanthin—have a lower risk of developing AMD. The most important thing you can do for your eyes is eat a lot of leafy green veggies and fish. A diet rich in vitamins A, C, E, zinc and omega 3 fatty acids is a great way to protect your vision. 

AREDS and AREDS2 are registered trademarks of the United States Department of Health and Human Services (HHS).