June 6, 2018
A tribute to Jeff
I am late in writing this quarterly blog as I have been mourning the passing of a dear friend and colleague, Jeffrey Bernstein, MD. Jeff was a vascular surgeon at The Doctors Clinic in Bremerton for over twenty years before his transition to the PolyClinic in Seattle a few years ago. I met Jeff at the Kitsap County Medical Society a few weeks after I started practicing here and we have been friends ever since. We were in a book group together with our wives and several other couples; and we convened every few months for all these years to discuss literature as a pretext to drink wine. Jeff was perhaps the most articulate person that I have ever met. He had strong convictions and opinions over a wide range of subjects. While I often disagreed with him, particularly when it came to politics, I always respected what he had to say.
Jeff was working up until the day before he came down with the diagnosis of glioblastoma multiforme, the same type of brain cancer that struck John McCain, Ted Kennedy and Beau Biden. He saw 17 patients the day before Thanksgiving 2016 and developed his first of many seizures the following day. Other than a slower recall of information, there was absolutely no warning sign. With the support of his family and friends, Jeff battled the cancer courageously. It was painful to watch him from being a man of eloquence to practically monosyllabic. He stopped comprehending what he read soon after the diagnosis, but still tried to participate in our book group through audiobooks. He never smoked, ate and drank sensibly; exercised often (I was swimming with him at the Y two months before his death). In short, he did all the right things but fate is blinded to virtues; and a great man was lost among us. Jeff was 64.
Couple of weeks after Jeff’s passing, I saw a longtime patient of mine at the office. He is 90, sharp as a whip, and in excellent health. I asked him what his secret was to a long life and health. He replied by saying that he is the perfect specimen for a graduate student in nutrition. He does not consume alcohol, tobacco or dessert; eats the same nutritious meal three times a day (in small portion, mind you) for the past thirty years. He has cravings like everyone else, but takes great pride in fighting off the temptations. I truly admire his will power but I know I can’t do it. And to what end? I immediately thought of Jeff. If I were guaranteed thirty more years through a Herculean act of redemption, would I take it? My choice is made easy, as there is indeed no guarantee in life. But it is worthwhile to contemplate a middle road approach by giving and taking joy in eating while harnessing the power of nutrition for health.
Have you ever wondered whether taking vitamins and or mineral supplements can help prevent, treat or cure eye conditions? Does our mothers’ admonition to eat carrot for good eyesight carry any truth? Scientists long suspected that zinc and antioxidants have the potential to prevent or slow the progression of cataract and age related macular degeneration. The Age Related Eye Disease Study, or AREDS, conducted by the National Eye Institute and concluded in 2001 was a randomized clinical trial that enrolled 4757 patients at 11 centers to evaluate the effect of high-dose micronutrient supplements consisting of antioxidants and vitamins (500 mg Vitamin C, 400 IU Vitamin E and 15 mg beta carotene) and zinc (80mg zinc oxide and 2mg cupric oxide) on Age-related macular degeneration (AMD) and vision loss. Individuals with bilateral intermediate AMD or advanced unilateral AMD had a 25% reduction of risk for progression to advanced AMD and a 19% risk reduction in rates of moderate vision loss (> 3 lines of visual acuity) by 5 years. Patients were treated for 6.5 years but the treatment effect was present even after 10 years. By that time, 44% of placebo recipients compared with 34% of the supplement recipients had advanced AMD, a 27% risk reduction.
However, subjects with no AMD or only early AMD did not derive any benefit.
In AREDS, investigators found that patients who are heavy smokers may need to be careful about taking beta carotene because large clinical trials showed this supplement increases the risk of lung cancers. Beta carotene is a pigment found in plants that gives yellow and orange fruits and vegetable their color. It was crystallized from carrot roots, hence the name carotene. In the human body, beta carotene is converted into Vitamin A.
Another related class of pigment is Xantophylls. Xantohphylls contain oxygen molecule whereas carotenes are pure hydrocarbon with no oxygen in them. Xantophylls and carotenes are collectively known as carotenoids. Carotenoids may protect our eyes against light damage because they are efficient absorbers of blue light. Several large studies suggest that lutein and zeaxanthin, which are Xantophylls, may help patients with advanced AMD. These two pigments are present in the macula, the most central and critical part of the retina, and they are much more concentrated there than anywhere else in the body.
In the subsequent study, AREDS 2, investigators sought to improve on the AREDS 1 formulation by eliminating beta-carotene (to reduce the risk of lung cancers in smokers) but adding 10 mg of lutein and 2 mg of zeaxanthin. They found a slight reduction in risk of advanced AMD, particularly in subjects whose diets have low level of lutein and zeaxanthin.
Further, investigators found that lowering the zinc component to 25mg did not affect the effect of the formula. Nor did they find any beneficial effect of adding omega 3 long chain polyunsaturated fatty acids such as DHA and EPA.
AREDS 2 formula is commercially available and can be purchased over the counter at your local pharmacy. PreserVision by Bausch and Lomb is one such formulation that has to be taken twice daily. While taking these supplements might help reduce the risk of AMD for the appropriate individuals, it is important to emphasize that obesity reduction, smoking cessation, and blood pressure control may all help with AMD.
What about other retinal conditions such as retinitis pigmentosa? One large study concluded that high daily doses of vitamin A palmitate (15,000 IU/day) can slow the decline in the electoretinogram response in patients with retinitis pigmentosa by about 20% per year. It is not clear if there is any clinical or functional benefits, they just tested better. High dose Vitamin A can cause liver damage and can be harmful to the fetus. So pregnant women should refrain.
Omega 3 fatty acids have anti-inflammatory properties. While supplementation with DHA, or its precursors EPA, showed no benefit for AMD, they have a definite role in the treatment of dry eye syndrome. Dry eye syndrome is really a chronic inflammatory disorder due to tear film instability and tear hyperosmolarity. A Mediterranean diet that is rich in Omega-3 fatty acids is not only in and of itself anti-inflammatory but it also suppresses the inflammatory effects of Omega-6 fatty acids. A ratio of 4 Omega-6 to 1 Omega-3 appears to be ideal for most people. While many studies showed the benefits of Omega-3, which is rich in fish and flax seed, for dry eye disease; there is no uniformity as to exactly what kind of Omega-3 and in what dosage. Nordic fish oil and Hydroeye are two brands that are often recommended as supplement for Dry Eye disease.
Ginkgo biloba and Taurine are thought to increase ocular blood flow and may have a protective effect against glaucoma. More studies are needed in this area but I think that Nitric Oxide hold great promise. This molecule is a vasodilator. It relaxes the muscles that surround our blood vessels, causing the vessels to widen, thereby increasing blood flow and lower blood pressure. It is commonly used as a supplement for body builders to support muscle growth. It is also thought that nitric oxide may also relax the drainage channels of the eye, allowing fluid to flow out of the eye easier. Vyzulta is a new glaucoma drop in the market that has a nitric oxide molecule bound to a well-known glaucoma medication, latanoprost. This addition of nitric oxide demonstrated a statistically significant effect on lowering the intraocular pressure at Day 7, 14 and at 28. At this time, it is unknown if oral nitric oxide as a supplement will demonstrate the same benefit though.