All of us are familiar with over-the-counter nutritional supplements, yet many of us may not have ever heard of nutraceutical medical food.
To explain the difference and how they will be referenced in this article:
- Dietary supplements are purchased over-the-counter and intended for people to add vitamins, minerals, herbs or amino acids to an otherwise healthy lifestyle.
- Nutraceutical medical foods, also referred to as nutraceuticals or medical food, are formulated to treat a specific disease or medical condition, are regulated by the FDA, and must also be used under the supervision of a physician.
This article was inspired by Dr. Eric Conley’s CE lecture “Nutraceuticals in the Treatment of Glaucoma” presented at the 2021 Eyes On Glaucoma event. I routinely recommend vitamin supplementation for my patients for a number of conditions, based on this guide, so when I heard of medical foods, I was intrigued at how they can further benefit my patients.
This article will summarize nutraceutical medical food, the benefits it can provide for specific ocular diseases, and how you can incorporate them into your practice.
Mitochondrial dysfunction: The origin of disease
The eye has an extremely high metabolic demand to complete its daily functions of visual processing and is thus prone to oxidative damage. Remember that the energy demands of our cells are fulfilled by the mitochondria—or energy powerhouse. This means that the eye also creates a significant amount of reactive oxygen species (ROS), or free radicals, as byproducts of energy production.
This oxidative stress leads to inflammation and damage of DNA, RNA, mitochondria, and the cell itself. If left untreated, these damaged cells will undergo apoptosis or programmed cell death. If, however, these cells can be revived before apoptosis, we have the opportunity to prevent cell death, vision loss, and progression of ocular diseases such as glaucoma and macular degeneration.
The question is, how do we do this? Well, free radicals can be neutralized if there are antioxidants available in the mitochondria of our cells. This means we need to have a high serum concentration of antioxidants available to fight disease. How do we achieve high serum concentration of antioxidants? That’s where nutraceuticals come into play.
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Download the Nutraceutical Medical Foods Cheat Sheet!
This cheat sheet covers a range of nutraceutical medical foods and their benefits.
Age-related macular degeneration
We’re already familiar with the main risk factors for developing age-related macular degeneration: aging, smoking, genetics, and UV and blue light exposure. All of these can result in increased oxidative stress which leads to mitochondrial DNA damage, disruption to mitochondrial function, increased reactive oxygen species (ROS), and eventually cellular apoptosis.
In fact, retinal tissue from human donors with AMD have been shown to have damaged mitochondrial structure, disturbances to the mitochondrial DNA, and fewer numbers of mitochondria than donors without AMD.
Figure 1 illustrates mitochondrial involvement in dry AMD.
Figure 1: Adapted from mdpi.com.
For a full-size version of this image, click here.
The goal of nutraceuticals is to intervene before cellular apoptosis occurs. This could be considered when patients have a strong family history of AMD, early clinical signs of the disease, or a reduced macular pigment optical density (MPOD). Our current therapies for AMD (AREDS2 supplementation or Anti-VEGF injections) have only been able to slow down but not stop the progression of the disease.
We already know from AREDS2 that nutritional supplementation can impact the disease course of moderate to advanced disease, so prescribed nutraceutical medical food isn’t too much farther of a leap to make.
Lumega-Z is the only FDA-regulated nutraceutical medical food to treat AMD. Lumega-Z is a micronized lipid liquid formulation of antioxidants, vitamins, and anti-inflammatory components that aim to restore macular pigment and mitochondrial function. When considering nutraceuticals or vitamin supplements, absorption is crucial to outcome. Although Lumega-Z contains some of the same components as AREDS2, when they were compared in a head-to-head study, those taking Lumega-Z had 4x the serum levels of lutein, zeaxanthin, and mesoxanthin when compared to those taking Preservision.
Additionally, contrast sensitivity was improved in the Lumega-Z group compared with the AREDS2 group.
The graph in Figure 2 shows the blood serum concentration of lutein, zeaxanthin and meso-zeaxanthin in a trial of patients taking Preservision AREDS2 vitamins versus those taking Lumega-Z during the first 12 weeks of the study.
Figure 2: Adapted from ncbi.nlm.nih.gov.
For a full-size version of this image, click here.
Next we’ll review the main ingredients in Lumega-Z and how they can work to protect the macula. Omega-Boost is a separate bottle of omega-3 supplementation that comes included with the purchase of Lumega-Z.
Lumega-Z Main Ingredients
| Micronutrients | Nutrient Amount |
|---|---|
| Proprietary Ocular Carotenoid Formula | Nutrient Amount |
| Antioxidants | Nutrient Amount |
| Proprietary Ocular Antioxidant Blend | Nutrient Amount |
| Anti-inflammatories | Nutrient Amount |
| Vitamin C (as ascorbic acid and calcium ascorbate) | 500 mg |
| Vitamin D3 (as cholecalciferolin MCT) | 2000 IU |
| Vitamin E (as mixed tocopherols with not less than 50 mg of gamma tocopherol) | 200 IU |
| Thiamin (vitamin B1 as thiamin HCL) | 1.5 mg |
| Riboflavin | 1.7 mg |
| Vitamin B3 (Niacin as niacinamide) | 20 mg |
| Vitamin B3 (as pyridoxine HCI) | 10 mg |
| Folate (as folic acid) | 800 mcg |
| Vitamin B12 (as methylcobalamin) | 1000 mg |
| Biotin | 100 mcg |
| Pantothenic Acid (as d-calcium pantothenate) | 10 mg |
| Calcium (as calcium lactate gluconate) | 250 mg |
| Magnesium (as lactate gluconate) | 100 mg |
| Zinc (as zinc amino acid chelate) | 25 mg |
| Selenium (as selenium sodium selenate) | 70 mcg |
| Copper (as copper gluconate) | 2 mg |
| Manganese (as manganese gluconate) | 2 mg |
| Chromium (as chromium picolinate) | 120 mcg |
| Molybdenum (glycinate chelate) | 75 mcg |
| Lutein, Meso-zeaxanthin, Zeaxanthin, Lycopene | 28.5 mg |
| Astaxanthin (as AstaReal) | 4 mg |
| NAC (N-acetyl-cysteine) | 500 mg |
| L-Taurine | 500 mg |
| billiberry fruit extraxt 4:1, alpha lipoic acid | 200 mg |
| Acetyl-L-Carnitine | 500 mg |
| CoQ10 (as ubiquinone) | 50 mg |
| Quercetin | 100 mg |
To see a full list of Lumega-Z & Omega Boost ingredients.
Lumega-Z main ingredients
Carotenoids: lutein (L), zeaxanthin (Z) and meso-zeaxanthin (MZ) have antioxidant, anti-inflammatory and anti-autophagy properties. They are some of the most potent scavengers of reactive oxygen species (meaning they neutralize oxidative damage). They are found in highest concentration in the center of the fovea (MZ), mid-periphery of the macula (Z), and periphery of the macula (L). When given in 1:1:1 concentration, they are more potent than any individual carotenoid alone.
Carotenoids cannot be synthesized by humans, we must consume them. While we can find lutein and zeaxanthin in foods like leafy green vegetables and egg yolks, their bioavailability is not sufficient (and the quantity needed to consume is unrealistic) especially for those who already have signs of disease. Meso-zeaxanthin is a metabolite of lutein and zeaxanthin and not found in foods.
Astaxanthin: a red algae derivative is an extremely potent antioxidant. In fact, it is 6000x more effective at neutralizing free radicals compared with Vitamin C, which most of us typically think of as a powerhouse antioxidant. One study showed improvement in visual acuity, contrast sensitivity, and visual function questionnaire scores with 2 years use of astaxanthin, lutein, and zeaxanthin.
Figure 4 demonstrates how astaxanthin is 6000x more efficient of an antioxidant than Vitamin C.
Figure 4
Functions of main ingredients
- NAC: N-acetyl L-cysteine, the precursor to the potent antioxidant glutathione, can protect the RPE from oxidative damage by preventing accumulation of ROS which, in turn, prevents mitochondrial dysfunction and cell death.
- Acetyl L-carnitine: prevents oxidative damage by increasing glutathione production.
- CoQ10: Coenzyme-Q 10 is a lipid soluble antioxidant that assists mitochondria with neutralizing free radicals; can also prevent neuroretinal damage.
- Quercetin: is a dietary polyphenol that can directly bind free radicals and prevent choroidal neovascularization.
- Bilberry extract: antioxidant with the potential to limit light-induced retinal apoptosis.
Glaucoma
In much the same way that oxidative stress and mitochondrial dysfunction are implicated in the development of AMD, they also play a role in the pathophysiology of glaucoma through a number of avenues. Mitochondrial damage has been shown to cause retinal ganglion cell death. Studies have also shown increased serum and aqueous concentration of oxidative stress in patients with glaucoma.
Damage to the mitochondrial DNA combined with genetic and environmental factors (such as elevated IOP, reduced blood flow to the optic nerve or reduced optic nerve perfusion pressure) can also lead to mitochondrial dysfunction. This then reduces the ability to produce ATP (energy) and increases the generation of free radicals. Ultimately, this leads to damaged retinal ganglion cells and the optic nerve degeneration that we call glaucoma.
The schematic in Figure 5 shows factors leading to mitochondrial dysfunction and optic nerve degeneration in glaucoma.
Figure 5
GlaucoCetin
Antioxidants have been shown to reduce oxidative stress in the trabecular meshwork as well as protect the retinal ganglion cells from death. GlaucoCetin is the only medical food created to help stop mitochondrial damage of the optic nerve and prevent vision loss in patients with glaucoma. It works through potent antioxidant therapy, enhancing blood flow to the optic nerve, and protecting retinal ganglion cells. GlaucoCetin comes in a powder form that patients mix with any liquid to consume.
GlaucoCetin Main Ingredients
| Ingredients | Nutrient Amount |
|---|---|
| Curcumin (as CurcuWIN)(Curcuma longa L)(Rhizomes) | 500 mg |
| L-Taurine | 500 mg |
| N-Acetyl Cysteine | 400 mg |
| Niacinamide (B3) | 250 mg |
| Ginkgo Biloba | 120 mg |
| Lipoic Acid | 100 mg |
| Citicoline (as Cognizin) | 100 mg |
| Grape Seed Extract (98% Polyphenols) | 100 mg |
| Green Tea Leaf Extract (98% Polyphenols) | 100 mg |
| Coenzyme Q10 | 100 mg |
| Biotin 1% | 10 mg |
| Natural Astsxanthin (as AstaReal)(Haematococcus pluvialis algae extract) | 4 mg |
| Proprietary Flavenoid Complex: Fisetin (Rhus succedenea)(stem) Quercetin, Luteolin | 250 mg |
To see a full list of GlaucoCetin ingredients.
Functions of main ingredients
- Curcumin: is a natural antioxidant, anti-inflammatory, anti-mutagenic, anti-microbial, anti-cancer, and works via a number of pathways to protect the retinal ganglion cells and optic nerve from mitochondrial dysfunction.
- Grape seed extract: can protect against oxidative damage to retinal ganglion cells
- CoQ10: protects against DNA damage, enhances mitochondrial function and acts as an antioxidant.
- Astaxanthin: the “super-antioxidant” can enter the cell and act directly in an anti-inflammatory capacity working on interleukins and tumor necrosis factor. It can even turn off apoptosis and heal oxidative stress.
- Ginkgo biloba: a polyphenol flavonoid that improves microcirculation around the optic nerve and enhances mitochondrial energy production and cell membranes.
- Alpha lipoic acid: helps protect RGCs from cell death.
- B3: has been shown to benefit patients with glaucoma, independent of IOP, especially in those with NTG.
How to prescribe
In order for patients to order either Lumega-Z or GlaucoCetin, you, their eyecare provider, must first create a Doctor Authorization Code (DAC) with the parent company, Guardion Health Sciences. Patients will then enter your DAC to be able to order the product you recommend.
In addition to granting patient access to the medical food, this system also allows the provider to receive a quarterly list of patients actively ordering their nutraceuticals so you can keep track of who is using the treatment and with what frequency. (Similar to how we like to know how frequently a patient picks up their glaucoma drops from the pharmacy.)
Costs
At the time of publishing this article, GlaucoCetin costs $79.95 for a 28 day supply. The patient saves 5% if the patient enrolls in autoship. Lumega-Z costs $49.99 per month with various savings for different shipment options. Selling directly from your practice is also an option.
Conclusion
When we think of ocular diseases in terms of mitochondrial dysfunction and oxidative stress, we can see the beneficial role nutraceuticals can have for many of our patients. While this article discusses specifically Lumega-Z and GlaucoCetin in the treatment of macular degeneration and treatment of glaucoma, respectively, many of the nutrients discussed have also been studied for other ocular diseases such as diabetic retinopathy. However at this time, the treatments discussed here are only studied for AMD and glaucoma.
While the standard of care treatment for glaucoma and macular degeneration have their benefits, it’s becoming more and more necessary to think outside the box. When our patients have a blinding eye disease, we should feel responsible for sharing with them all the potential treatments that could help preserve their vision, including nutraceuticals, much in the same way we stay up to date on the latest Anti-VEGF and MIGS treatment options.
As eyecare providers, we must familiarize ourselves with nutraceuticals to be able to confidently prescribe them for our patients and provide the most comprehensive care.
