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You are What You EatYou are What You EatNutrition in Eye CareNutrition in Eye Care

Scot Morris, O.D., F.A.A.O.Scot Morris, O.D., F.A.A.O.

Eye Consultants of Colorado, LLCEye Consultants of Colorado, LLCwww.eyeconsultantsofco.comwww.eyeconsultantsofco.com

smorris@eyeconsultantsofco.comsmorris@eyeconsultantsofco.com

Morris Education & Consulting AssociatesMorris Education & Consulting Associateswww.mecace.comwww.mecace.com

Speaker Bureaus & Consultant BoardsSpeaker Bureaus & Consultant Boards

AllerganAllergan InspireInspireAdvanced Medical OpticsAdvanced Medical Optics OdysseyOdysseyBausch & LombBausch & Lomb VistakonVistakonCarl Carl ZeissZeiss VSPVSPEye MedEye Med

DisclosuresDisclosures

You are What You EatYou are What You EatNutrition in Eye CareNutrition in Eye Care

Some Things to Think AboutSome Things to Think AboutMultiMulti--Billion dollar a year industry without Billion dollar a year industry without FDA regulationFDA regulation

Regulated by 1994 DSHEARegulated by 1994 DSHEANutritional supplements 20.3BNutritional supplements 20.3B11

The Sports Drink industry 12.5BThe Sports Drink industry 12.5B

NIH funding for dietary research 117B in NIH funding for dietary research 117B in 20022002

1.1. Supplement Business Report 2005. Supplement Business Report 2005. NutrNutr Bus Bus JrnlJrnl Oct 2005Oct 2005

PrePre--Lecture QuizLecture Quiz1.1. How are beta carotene, How are beta carotene, LuteinLutein and and VitVit. A related. A related2.2. T/FT/F Is there more Vitamin A in a carrot than a Is there more Vitamin A in a carrot than a

sweet potatosweet potato3.3. T/FT/F VitVit A & E compete for absorptionA & E compete for absorption4.4. T/FT/F Vitamin A helps reduce risk of ARMDVitamin A helps reduce risk of ARMD5.5. T/FT/F Too much Too much VitVit A can cause birth defectsA can cause birth defects6.6. T/FT/F VitVit C and C and bioflavanoiodsbioflavanoiods help support help support

collagen production & stronger capillary wallscollagen production & stronger capillary walls7.7. T/FT/F 1 red pepper has more vitamin C than 4 1 red pepper has more vitamin C than 4

orangesoranges8.8. T/FT/F We need more Vitamins than the RDAWe need more Vitamins than the RDA9.9. T/FT/F We store Vitamin C in our skinWe store Vitamin C in our skin

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PrePre--Lecture Quiz Lecture Quiz (cont)(cont)

10.10. T/FT/F Vitamin C can help reduce risk of CataractsVitamin C can help reduce risk of Cataracts11.11. T/FT/F Vitamin E acts to thin the bloodVitamin E acts to thin the blood12.12. T/FT/F French fries are a great source of omegaFrench fries are a great source of omega--6613.13. T/FT/F 6:1 is the ideal ratio of omega 66:1 is the ideal ratio of omega 6-- to to --3314.14. T/FT/F The AREDS study reviewed the effect of The AREDS study reviewed the effect of

luteinlutein on ARMDon ARMD15.15. T/FT/F According to AREDS supplements reduce According to AREDS supplements reduce

risk of all forms of ARMDrisk of all forms of ARMD16.16. T/FT/F One cigarette destroys 25One cigarette destroys 25--100 mg of 100 mg of

vitamin C!vitamin C!17.17. T/FT/F We should take 500We should take 500--1000 mg Vitamin C/day1000 mg Vitamin C/day

OutlineOutlineVitaminsVitaminsMineralsMineralsOthersOthers

Fatty AcidsFatty AcidsHerbalsHerbalsMiscellaneousMiscellaneous

WebsitesWebsiteswww.nutritionfocus.comwww.nutritionfocus.comwww.nutrition.govwww.nutrition.govwww.elook.org/nutritionwww.elook.org/nutritionwww.vitaminswww.vitamins--nutrition.orgnutrition.org

The Oxidation WarThe Oxidation WarWhat is a free radical?What is a free radical?What do they do?What do they do?

It is estimated that every cell in our body takes 10,000 free raIt is estimated that every cell in our body takes 10,000 free radical hits in a dical hits in a twentytwenty--four hour periodfour hour period

The Oxidation WarThe Oxidation War

How do AntiHow do Anti--oxidants workoxidants workThey give off electrons to stabilize the free radicalThey give off electrons to stabilize the free radicalAntioxidants work synergisticallyAntioxidants work synergistically

C

E

A

e e

ACE Triad

e

The ABC & DEThe ABC & DE’’s of Healths of HealthVitaminsVitamins

A & the A & the CarotenoidsCarotenoidsB ComplexesB ComplexesC & the C & the BioflavenoidsBioflavenoidsDDEE How They WorkHow They Work

Where Do We Get ThemWhere Do We Get ThemHow Much Do We NeedHow Much Do We NeedEffects on Vision & Ocular HealthEffects on Vision & Ocular HealthSide Effects/InteractionsSide Effects/InteractionsInteresting FactsInteresting Facts

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A & the A & the CarotenoidsCarotenoidsWhat Are TheyWhat Are They

Preformed Vitamin APreformed Vitamin AVitamin A (Retinol)Vitamin A (Retinol)

ProvitaminProvitamin AACarotenoidsCarotenoids (563)(563)

Beta CaroteneBeta CaroteneConverted into A as neededConverted into A as needed

XanthophyllsXanthophyllsLuteinLuteinZeaxanthinZeaxanthin

made by body from made by body from LuteinLuteinLycopene

A & the A & the CarotenoidsCarotenoidsHow They WorkHow They Work

Ocular FunctionOcular FunctionAntiAnti--oxidant actionoxidant actionAids in the maintenance Aids in the maintenance of good eyesightof good eyesight

Activates the visual Activates the visual pigment pigment rhodopsinrhodopsin

General FunctionGeneral FunctionAids in growth/repair of body tissuesAids in growth/repair of body tissuesMaintains smooth, soft skinMaintains smooth, soft skinProtects (by strengthening cell walls) Protects (by strengthening cell walls) the mucous membranesthe mucous membranesProtects the linings of the digestive Protects the linings of the digestive tract, kidneys and bladdertract, kidneys and bladderBuilds strong bones and teethBuilds strong bones and teethHelps in the formation of blood cellsHelps in the formation of blood cellsEnhances RNA productionEnhances RNA productionIncrease sperm countIncrease sperm countEnergizes immune systemEnergizes immune systemHelps convert cholesterol into female Helps convert cholesterol into female estrogens and male androgens.estrogens and male androgens.

A & the A & the CarotenoidsCarotenoidsHow Much Do We NeedHow Much Do We Need

USDA of Vitamin A USDA of Vitamin A palmitatepalmitateMen 1,000 mcgMen 1,000 mcgWomen 800 mcgWomen 800 mcgThere is currently no RDA for betaThere is currently no RDA for beta--carotene, carotene, luteinlutein, , zeaxanthinzeaxanthin, , lycopenelycopene

33--6 mg6 mg5:1 5:1 LuteinLutein to Zeaxanthinto Zeaxanthin11

How is this determinedHow is this determined1 Retinol Equivalent=10 IU for plants1 Retinol Equivalent=10 IU for plants1 RE=3.3 IU for animal products1 RE=3.3 IU for animal products

24002400LactationLactation

16001600PregnancyPregnancy

2000/16002000/160051 years+51 years+

2000/16002000/16001111--50 years50 years

1400/14001400/140077--10 years10 years

1000/10001000/100044--6 years6 years

800/800800/80011--3 years3 years

750/750750/75000--1 years1 years

(mcg)(mcg)♂♂//♀♀ RDA RDA

Junghans A, Seis H, Sal W. Macular pigments lutein and zeaxanthin as blue light filters studies in liposomes. Arch Biochem Biophys 2001, Jul 15; 391(2): 16-4

A & the A & the CarotenoidsCarotenoidsWhere do We Get ThemWhere do We Get Them

PlantPlantRed, yellow and orange fruits Red, yellow and orange fruits and vegetablesand vegetablesGreen, leafy vegetablesGreen, leafy vegetables

AnimalAnimalLiver and butter are a great Liver and butter are a great source of source of luteinlutein

61651973 ( 1 liver)Liver, chicken

1050311868 (4 oz or 113g)Liver, beef

300034080 / tablespoonCod Liver Oil

3221092 (1 cup, cubed)Canteloupe

389596 (1 cup, chopped)Mango

570849 (1 cup, chopped)Red Pepper

890596 (1 cup chopped)Kale

20062668 (1 potato)Sweet Potato

28132025 (1 carrot)Carrot

RE in 100 g serving

RE IN NORMAL SERVINGFoods

A & the A & the CarotenoidsCarotenoidsSupplementation TipsSupplementation Tips

Better to take beta carotene or Better to take beta carotene or AquafasolAquafasol A in oil base to A in oil base to enhance absorptionenhance absorption

Body converts what it needs and stores the rest in the skin, Body converts what it needs and stores the rest in the skin, preventing excess storage in the liver.preventing excess storage in the liver.Beta carotene competes for transport space with Beta carotene competes for transport space with luteinlutein and and zeaxanthinzeaxanthin

Vitamin A Vitamin A palmitatepalmitate, beta carotene, , beta carotene, luteinlutein and vitamin E and vitamin E are fat solubleare fat soluble

Competitive Absorption in the GI, storage in the liver Competitive Absorption in the GI, storage in the liver and transport from the liver to the retina.and transport from the liver to the retina.Avoid problems: Take food supplements at different Avoid problems: Take food supplements at different timestimesBlood levels decrease immediately upon cessationBlood levels decrease immediately upon cessation

A & the A & the CarotenoidsCarotenoidsEffects on Vision & Ocular HealthEffects on Vision & Ocular Health

Retina/MaculaRetina/MaculaIn 2001, data from the Third National Health and Nutrition In 2001, data from the Third National Health and Nutrition Examination Survey reported that higher intakes of Examination Survey reported that higher intakes of luteinlutein and and zeaxanthinzeaxanthin among people ages 40among people ages 40--59 may be associated with 59 may be associated with a reduced risk of advanced AMD.a reduced risk of advanced AMD.In 1994, a National Eye Institute (NEI)In 1994, a National Eye Institute (NEI)--AREDS study indicated AREDS study indicated that consumption of foods rich in that consumption of foods rich in carotenoidscarotenoids was associated was associated with a reduced risk of developing AMD.with a reduced risk of developing AMD.NIH Study found that high NIH Study found that high carotenoidcarotenoid intake had 43% lower intake had 43% lower risk of developing ARMDrisk of developing ARMDVitamin A may help to prevent/retard the RP progressionVitamin A may help to prevent/retard the RP progression

Vitamin A has NOT been proven to save nor improve sight, only Vitamin A has NOT been proven to save nor improve sight, only slow down the progress of the disease by 7 years if a nutritionaslow down the progress of the disease by 7 years if a nutritional l regimen is begun early in life.regimen is begun early in life.

LuteinLutein had been shown to increases CS and had been shown to increases CS and photopicphotopicsensitivitysensitivityVitamin A shown to increase Vitamin A shown to increase scotopicscotopic sensitivity sensitivity

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A & the A & the CarotenoidsCarotenoidsEffects on Vision & Ocular HealthEffects on Vision & Ocular Health

CataractIn 1999, data from the Nurses Health Study showed In 1999, data from the Nurses Health Study showed a reduced likelihood of cataract surgery with a reduced likelihood of cataract surgery with increasing intakes of increasing intakes of luteinlutein and another and another carotenoidcarotenoid----zeaxanthinzeaxanthin..

People with high People with high luteinlutein levels have a 19levels have a 19--22% less risk of 22% less risk of the incidence of cataractsthe incidence of cataracts

In 1999, the Health Professionals FollowIn 1999, the Health Professionals Follow--up Study up Study found a trend toward a lower risk of cataract found a trend toward a lower risk of cataract extraction with higher intakes of extraction with higher intakes of luteinlutein and and zeaxanthinzeaxanthin..In 1999, the Beaver Dam Study In 1999, the Beaver Dam Study ---- concluded that concluded that people with diets higher in people with diets higher in luteinlutein and and zeaxanthinzeaxanthinhad a lower risk of developing cataract.had a lower risk of developing cataract.

A & the A & the CarotenoidsCarotenoidsSide Effects/ InteractionsSide Effects/ Interactions

Serious:Serious:>10,000 IU can lead to birth defects>10,000 IU can lead to birth defects50,000 50,000 IU'sIU's ((provitaminprovitamin A) daily may be toxicA) daily may be toxic

7.5 mg dry & 7.5 mg dry & pruriticpruritic skin, skin, erythematouserythematous dermatitis, dermatitis, cracked lips, pain & bone tenderness, fatigue, irritability, cracked lips, pain & bone tenderness, fatigue, irritability, edema, papilledema.edema, papilledema.

18,500 18,500 IU'sIU's ((provitaminprovitamin A) daily for 1A) daily for 1--3 months toxic for 3 months toxic for infantsinfants

Headache, nausea, vomiting, dizziness, eyeball protrusion, Headache, nausea, vomiting, dizziness, eyeball protrusion, double vision, and brain swelling.double vision, and brain swelling.

25,000 25,000 IU'sIU's ((provitaminprovitamin A) can produce liver damageA) can produce liver damageLarge doses lead to anemia and gout, anemia, blurred Large doses lead to anemia and gout, anemia, blurred vision, bone pain, diarrhea, fatigue, gout, hair loss, bone vision, bone pain, diarrhea, fatigue, gout, hair loss, bone fragility, headaches, irregular periods, liver enlargement, fragility, headaches, irregular periods, liver enlargement, nausea, vomiting, deep bone pain, reduced thyroid activitynausea, vomiting, deep bone pain, reduced thyroid activity

Hepatic Toxicity are Hepatic Toxicity are incrediblyincredibly rarerare

A & the A & the CarotenoidsCarotenoidsInteresting FactsInteresting Facts

Smokers & Drinkers:Smokers & Drinkers:Tobacco inhibits absorption and alcohol depletes current Tobacco inhibits absorption and alcohol depletes current levelslevels

Alpha Alpha TocopherolTocopherol Beta Carotene Cancer Prevention Study Beta Carotene Cancer Prevention Study Group (1994) Group (1994)

vitamin A supplementation in male smokers increased the risk of vitamin A supplementation in male smokers increased the risk of lung cancerlung cancer

No Alcohol: interferes with vitamin A and zinc metabolism in thNo Alcohol: interferes with vitamin A and zinc metabolism in the e liver.liver.

XerophthalmiaXerophthalmiaPromotes health in all epithelial & mucosal tissuesPromotes health in all epithelial & mucosal tissues

MarigoldMarigold

B Complex VitaminsB Complex VitaminsHow They Work

These are critical components in cellular function, including recycling antioxidants.

Where Do We Get ThemHow Much Do We Need

B1 (Thiamine) B2 (Riboflavin)B3 (Niacin) B5 (Panothemic Acid)B6 (Pyroxidine) B9 (Folic Acid)B12 (Cyancobolamin)

Interesting FactsB6, B12 & folate help regulate homocysteine levelsPlasma Homocysteine levels have been linked to exudative ARMD1

Axer-Seigel R. Bouria D et Al. Assocaitaion of neovasccular ARMD and hyperhomocysteinermia. AJO 2004 Jan ; 137 (1) :84-9

C & the C & the BioflavanoidsBioflavanoids (P)(P)How They WorkHow They Work

Vitamin C, (ascorbic acid)Vitamin C, (ascorbic acid)Supports collagen productionSupports collagen productionActs as antioxidant to destroy free radicalsActs as antioxidant to destroy free radicalsAids in the absorption of ironAids in the absorption of ironSynthesis of bile saltsSynthesis of bile saltsAids in the metabolism of the amino acids phenylalanine and Aids in the metabolism of the amino acids phenylalanine and tyrosinetyrosineInvolved in folic acid metabolismInvolved in folic acid metabolismHelps form red blood cellsHelps form red blood cellsEssential in the formation of adrenalineEssential in the formation of adrenalineHelps prevent prostate cancer Helps prevent prostate cancer

BioflavonoidsBioflavonoidsHelp absorb vitamin CHelp absorb vitamin CAct as antiAct as anti--oxidantoxidantHelp protect/build stronger capillary walls.Help protect/build stronger capillary walls.

C & (P)C & (P)How Much Do We NeedHow Much Do We Need

Vitamin CVitamin CUS RDA: US RDA: 60 mg/day60 mg/day

We can not store Vitamin CWe can not store Vitamin CReality: Reality: 500500--1000 mg/day1000 mg/day

BioflavanoidsBioflavanoids::No US RDANo US RDAReality:Reality: 500 mg minimum500 mg minimum

SourcesSourcesBilberryBilberryQuercetinQuercetin (onions, apples and green tea)(onions, apples and green tea)RutinRutinHesperidinHesperidin

white part of fruitswhite part of fruitsAnthocyanosidesAnthocyanosides

peppers, grapes, garlic, berries,peppers, grapes, garlic, berries,

9595LactationLactation

7070PregnancyPregnancy

+60+6050 years50 years60601515--50 years50 years

50501111--14 years14 years454544--10 years10 years

404011--3 years3 years

35350.50.5--1 years1 years303000--0.5 years0.5 years

(mg/day)(mg/day)RDARDA

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C & the C & the bioflavanoidsbioflavanoids (P)(P)Where Do We Get ThemWhere Do We Get Them

Citrus fruits, berries, peppers, tropical fruits, Citrus fruits, berries, peppers, tropical fruits, potatoes and green, leafy vegetablespotatoes and green, leafy vegetables

5370 (1 med orange)Orange

4280 (1 cup)Canteloupe

3482 (1 cup)Grapefruit

28133 (a cup)Mango

3186 (1 cup)Raspberries

12080 (1 cup, chopped)Kale

9382 (1 cup, chopped)Broccoli

5786 (1 cup)Strawberry

89133 (1 cup,chopped)Green Pepper

190283 (1 cup, chopped)Red Pepper

100 g serving

Mg/servingVitamin CRich Foods

C & (P)C & (P)Effects on Vision & Ocular HealthEffects on Vision & Ocular Health

Cataract: Cataract: Blocks oxidative effects on the lens proteinsBlocks oxidative effects on the lens proteinsMay reduce the risk of PSC cataracts in nonMay reduce the risk of PSC cataracts in non--DM womenDM women

The American Journal of Clinical NutritionThe American Journal of Clinical Nutrition--March 2002March 2002Nurses' Health StudyNurses' Health Study

984 eyes examined, 34% cortical opacities & 13% PSC opacities984 eyes examined, 34% cortical opacities & 13% PSC opacitiesWomen <60 years with daily vitamin C intakes of >362 mg had Women <60 years with daily vitamin C intakes of >362 mg had a 57% lower odds ratio of developing cortical cataracts a 57% lower odds ratio of developing cortical cataracts compared women with intakes <140 mg. compared women with intakes <140 mg. Women who took vitamin C supplements for 10 years or more Women who took vitamin C supplements for 10 years or more reduced their risk for developing cortical cataracts by 60%, reduced their risk for developing cortical cataracts by 60%, compared with women who did not take vitamin C supplementscompared with women who did not take vitamin C supplementsAm J Am J ClinClin NutrNutr 2002;75:5402002;75:540--549549

C & (P)C & (P)Side Effects/InteractionsSide Effects/Interactions

Side Effects are rarekidney stonesanemia due to blood cell destruction in patients with G6PD (glucose 6-phosphate dehydrogenase) deficiency

C & (P)C & (P)Interesting FactsInteresting Facts

Vitreous humor/lens concentration Vitreous humor/lens concentration (10(10--50 x higher than the bloodstream)50 x higher than the bloodstream)

Wound HealingWound HealingClaims have been made that vitamin C can Claims have been made that vitamin C can preventpreventheart attacks, strokes, and certain cancersheart attacks, strokes, and certain cancers

Randomized, placebo controlled trials= inconsistent Randomized, placebo controlled trials= inconsistent resultsresultsInsufficient evidence to either confirm or refuteInsufficient evidence to either confirm or refute

The National Health and Nutrition Examination The National Health and Nutrition Examination Survey (NHANES III) Survey (NHANES III)

13% of US men and 9% of women have 13% of US men and 9% of women have VitVit C levels that are C levels that are so low they would be diagnosed as having scurvyso low they would be diagnosed as having scurvy

Potential Other UsesPotential Other Uses

Vitamin DVitamin DHow It WorksHow It Works

FatFat--soluble vitaminsoluble vitaminIngestionIngestion

Absorption in the upper small intestine with aid of bile Absorption in the upper small intestine with aid of bile salts. salts.

UV ExposureUV ExposureUV converts a form of cholesterol in the skin to vitamin DUV converts a form of cholesterol in the skin to vitamin D

WhatWhat’’s with s with VitVit. D & Calcium. D & CalciumVitamin D is stored in the liver & metabolized into Vitamin D is stored in the liver & metabolized into calcidiolcalcidiolKidneys convert into Kidneys convert into calcitriolcalcitriolAbsorbed into the blood where it is stored in fat Absorbed into the blood where it is stored in fat and muscle. and muscle.

CalcitriolCalcitriol: hormone that helps regulate body's Ca: hormone that helps regulate body's Ca2+2+ needs. needs.

Vitamin DVitamin DWhere Do We Get ThemWhere Do We Get Them

Two forms of Two forms of CalciferolCalciferolCholecalciferolCholecalciferol ((VitmainVitmain D3D3--animal origin)animal origin)ErgocalciferolErgocalciferol (Vitamin D2(Vitamin D2--plant origin)plant origin)

How Much Do We NeedHow Much Do We Need400400--1,000 IU/day (7.51,000 IU/day (7.5--10 10 ugug/day)/day)

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Vitamin DVitamin DSide Effects/ InteractionsSide Effects/ Interactions

Can be toxic in doses above 2000 IU/dayVitamin D toxicity can lead to excessively high blood calcium levels, constipation, kidney failure, nausea, weakness, and kidney stones

JAMA 1995; 274: 1683-86• 244 elderly patients evaluated who were confined to indoors for at least 6 months were likely to suffer from vitamin D deficiency

BMJ 2003 1 Vit D capsule q 4 months x 15 yrs decreased the risk of fractures by 22%, the risk of hip, vertebrae, wrist and forearm fracture by 33%.

Vitamin EVitamin EHow It WorksHow It Works

Acts as antiActs as anti--oxidantoxidantInteracts with Se to form glutathione Interacts with Se to form glutathione peroxidaseperoxidase

Helps prolong the life of Helps prolong the life of RBCRBC’’ss,,Essential role in cellular respiration.Essential role in cellular respiration.

Protects biological membranes found in the Protects biological membranes found in the nerves, muscles, and cardiovascular systemnerves, muscles, and cardiovascular systemHelps the body effectively use/store vitamin A Helps the body effectively use/store vitamin A and protects Band protects B--complex and vitamin C from complex and vitamin C from oxidation reactions. oxidation reactions. VasodilatorVasodilatorReduces risk of prostate cancerReduces risk of prostate cancerActs as anticoagulantActs as anticoagulantImproves capillary permeability Improves capillary permeability

Vitamin EVitamin EHow MuchHow Much

16.3916.39LactationLactation14.9014.90PregnancyPregnancy14.90/11.9214.90/11.9250 years+50 years+14.90/11.9214.90/11.921111--50 years50 years10.4310.4344--10 years10 years8.948.9411--3 years3 years5.965.960.50.5--1 years1 years4.474.4700--0.5 years0.5 years(mg/day)(mg/day)RDA Male/FemaleRDA Male/Female

Vitamin EVitamin EWhere Do We Get ItWhere Do We Get It

NutsNutsFatFat--soluble vitaminsoluble vitamin

Stored in adipose tissue, liver, and muscle, adrenal and Stored in adipose tissue, liver, and muscle, adrenal and pituitary glands, red blood cells and platelets, testes, and pituitary glands, red blood cells and platelets, testes, and ovariesovariesUnstable to heat, light, and oxygenUnstable to heat, light, and oxygen

SoynutsPistachios

2416 (half cup)Hazelnuts97 (half cup)Peanuts2417 (half cup)Almonds

Walnuts

5036 (half cup)Sunflower Seeds

Mg in 100servMg in normal servingsMg in normal servings

Vitamin EVitamin EEffects on Vision & HealthEffects on Vision & Health

James Robertson, of the Department of James Robertson, of the Department of Epidemiology at the University of Western Epidemiology at the University of Western Ontario in Canada, compared adults with Ontario in Canada, compared adults with cataracts to those without. cataracts to those without.

Findings: 300 to 600 mg supplemental vitamin Findings: 300 to 600 mg supplemental vitamin C reduced cataract risk by 70% and 400 IU C reduced cataract risk by 70% and 400 IU supplemental vitamin E for more than a year supplemental vitamin E for more than a year reduced cataract risk by 50%reduced cataract risk by 50%

EE

Side Effects/InteractionsSide Effects/InteractionsBlood thinnerBlood thinner

>11 mg/day toxic>11 mg/day toxic

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Vitamin EVitamin EInteresting FactsInteresting Facts

Protects Vitamin A (retinol ) from oxidizing. Protects Vitamin A (retinol ) from oxidizing. Protects lipids (Protects lipids (EFAEFA’’ss: fish, flax oil) from lipid : fish, flax oil) from lipid peroxidationperoxidation

Increases with exposure to sunlight or oxygenIncreases with exposure to sunlight or oxygenCompete for absorption with Compete for absorption with VitVit. A. ANot recommended for prevention/management of Not recommended for prevention/management of ROPROP

Vitamin KVitamin KWhat is It

Fat Soluable VitaminAbsorbed with fat

Where is It Found?Vitamin K1 is found naturally in plants. \Vitamin K2 is synthesized by bacteria in the intestinal tract ofhumans. Vitamin K3 is synthesized for industrial applications which can be converted into vitamin K2 in the intestinal tract of the body.

Natural sources of vitamin K1 consists of broccoli, cabbage, spinach, lettuce, turnip greens, green tea, beef liver, egg yolks, whole wheat, oats, soybeans, potatoes, butter, cheese, asparagus, tomatoes. Vitamin K2 sources are the bacterial flora in the ileum and jejunum.

FUNCTIONS Blood clotting mechanism

Synthesis of prothrombin

Vitamin KVitamin KSIDE EFFECTSSIDE EFFECTS(Possible) Hemolytic anemia in (Possible) Hemolytic anemia in infants, infants, hyperbilirubinemiahyperbilirubinemia, , jaundice, flush face, jaundice, flush face, indigestion, rash, skin itching.indigestion, rash, skin itching.Recommended dosageRecommended dosage

6565--80 mg 80 mg

6565LactationLactation6565PregnancyPregnancy6565808050+50+656580802525--5050606070701919--2424555565651515--1818454545451111--14143030303077--10102020202044--661515151511--33101010100.50.5--1 yrs1 yrs555500--0.5 yrs0.5 yrsFemaleFemaleMaleMaleAgeAge

MineralsMineralsSome minerals help body to absorb other Some minerals help body to absorb other nutrientsnutrients

SE (60SE (60--75 mcg)75 mcg)Helps absorb Vitamin EHelps absorb Vitamin Etrace mineral component of glutathione trace mineral component of glutathione peroxidaseperoxidase

CuCu500mg 500mg qhsqhs to act as a vasodilatorto act as a vasodilatorA copper deficiency has been theorized to be a cause A copper deficiency has been theorized to be a cause of atherosclerosis (hardening of the arteries)of atherosclerosis (hardening of the arteries)

MgMg500mg 500mg qhsqhs to act as a vasodilator, especially for to act as a vasodilator, especially for patients with circulatory problems, AMD and patients with circulatory problems, AMD and normal/low tension glaucoma. Improves normal/low tension glaucoma. Improves microperfusionmicroperfusion

Zn: Next slide pleaseZn: Next slide please

ZincZincMost common trace mineralMost common trace mineralFound in seafood, liver and eggsFound in seafood, liver and eggsHighly concentrated in the eye (retina Highly concentrated in the eye (retina and macula)and macula)Necessary for the action of over 100 Necessary for the action of over 100 enzymesenzymes

Integral part of Integral part of superoxidesuperoxide dismutasedismutaseand and catalasecatalaseNecessary for proper wound healingNecessary for proper wound healing

Scientific studies are not complete and Scientific studies are not complete and there is no agreement among doctors there is no agreement among doctors concerning the value of zinc concerning the value of zinc supplementssupplements?? If too much zinc interferes with ?? If too much zinc interferes with other trace mineralsother trace minerals

Essential Fatty AcidsEssential Fatty AcidsWhat Are TheyWhat Are They

Omega-3’sAlpha linoleic acid (LNA)

Omega-6Linoleic acid (LA)

Converted to Gamma Linoleic Acid (GLA)Omega-9

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Essential Fatty AcidsEssential Fatty AcidsHow They WorkHow They Work

Building blocks for all types of fat, lipids Building blocks for all types of fat, lipids and cholesterolsand cholesterolsEFAEFA’’ss are what is known as are what is known as polyunsaturated fatpolyunsaturated fatOxidation of omega 6 is the enemyOxidation of omega 6 is the enemy

Essential Fatty AcidsEssential Fatty AcidsWhere Do We Get ThemWhere Do We Get Them

Omega-3’sAlpha linoleic acid (LNA)

Body inefficiently converts LNA into the following drugs

eicosapentaeonic acid (EPA) docohexaenopic acid (DHA)

Essential Fatty AcidsEssential Fatty AcidsWhere Do We Get ThemWhere Do We Get Them

Omega-6Linoleic acid (LA)

Converted to Gamma Linoleic Acid (GLA)Converted to arachidonic acid (AA) & di-homo GLA

Black Current OilEvening Primrose

Essential Fatty AcidsEssential Fatty AcidsWhere Do We Get ThemWhere Do We Get Them

Omega-9Oleic acid (OA)2 TBSP / dayNuts

Fatty AcidsFatty AcidsHow Much Do We NeedHow Much Do We Need

OmegaOmega--33About 1000 mg/dayAbout 1000 mg/day0.65 g of EPA and DHA 0.65 g of EPA and DHA combinedcombined

200200--500 mg DHA500 mg DHA

OmegaOmega--66capped at around 4.44 gcapped at around 4.44 g

OmegaOmega--99

9

3 vs. 63 vs. 6

0.73g (3 oz, 85g)0.73g (3 oz, 85g)White tuna, can in waterWhite tuna, can in water

0.90g (1 can)0.90g (1 can)Sardines, canned in oilSardines, canned in oil

1.16g (1 fillet)1.16g (1 fillet)Blue fishBlue fish

0.82g (1 fillet)0.82g (1 fillet)Rainbow troutRainbow trout

1.6g (1/2 fillet)1.6g (1/2 fillet)Salmon, PinkSalmon, Pink

2.68g (1/2 fillet)2.68g (1/2 fillet)Salmon, ChinookSalmon, Chinook

3.25g (1 fillet)3.25g (1 fillet)MackeralMackeral, Pacific & Jack, Pacific & Jack

3.89g (1/2 fillet)3.89g (1/2 fillet)Salmon, AtlanticSalmon, Atlantic

2.43g (1 tbsp)2.43g (1 tbsp)Cod liver oilCod liver oil

2.83g (1 tbsp)2.83g (1 tbsp)Sardine oilSardine oil

Foods high in DHA/EPAFoods high in DHA/EPA

1.07 (1 tbsp)1.07 (1 tbsp)Olive oilOlive oil

8.67 (1/2 cup)8.67 (1/2 cup)AlmondsAlmonds1.95 (1 tbsp)1.95 (1 tbsp)Safflower oilSafflower oil

11.36 (1/2 cup)11.36 (1/2 cup)PeanutsPeanuts2.84 (1 tbsp)2.84 (1 tbsp)Canola oilCanola oil

20.98 (1/2 cup)20.98 (1/2 cup)Sunflower oils (dry roastedSunflower oils (dry roasted

4.8 (1 tbsp)4.8 (1 tbsp)Sunflower oil (hydrogenated)Sunflower oil (hydrogenated)25.53 (1/2 cup)25.53 (1/2 cup)Sunflower oil (roasted)Sunflower oil (roasted)

8.94 (1 tbsp)8.94 (1 tbsp)Sunflower oil (<60% LA)Sunflower oil (<60% LA)

Foods High in omegaFoods High in omega--66

Cold pressed oils are best

Fatty AcidsFatty AcidsEffects on Vision & Ocular HealthEffects on Vision & Ocular Health

OmegaOmega--3 protect against the risk of ARMD3 protect against the risk of ARMDA diet high in omegaA diet high in omega--6 (US diet) associated with an 6 (US diet) associated with an increased risk of advanced ARMDincreased risk of advanced ARMD

Side Effects/InteractionsSide Effects/InteractionsBlood thinnersBlood thinnersGI distressGI distressAcneAcne

Interesting FactsInteresting FactsCurrent ratio of omega 6:3 is 10Current ratio of omega 6:3 is 10--25:1 25:1

ideally would be 2:1 to 4:1 ideally would be 2:1 to 4:1 11StorageStorage

Institute of Medicine

ProteinsProteinsEssentialEssential

Histadine,isoleucineHistadine,isoleucine, , leucineleucine, lysine, , lysine, methioninemethionine, , phenylalanine, phenylalanine, threoninethreonine and and valinevaline

NonNon--essentialessential

OthersOthers1.1. GlutathioneGlutathione

Fights free radicals and acts as a detoxifierFights free radicals and acts as a detoxifier600mg/day in the form of onion, garlic, eggs and 600mg/day in the form of onion, garlic, eggs and avocadoavocado

2.2. NN--acetylacetyl--CysteineCysteine (NAC)(NAC)Raises intracellular levels of glutathione. Raises intracellular levels of glutathione.

3.3. Alpha Alpha lipoiclipoic acids acids Both 2 & 3 act as glutathione boostersBoth 2 & 3 act as glutathione boosters

4.4. Gingko Gingko BilobaBilobaIncrease blood flow to the eyes, interferes with platelet Increase blood flow to the eyes, interferes with platelet aggregation factor, and dilates blood vesselsaggregation factor, and dilates blood vesselsStabilizes micro blood vessel walls possibly influencing Stabilizes micro blood vessel walls possibly influencing retinal hemorrhages as in diabetic retinopathy.retinal hemorrhages as in diabetic retinopathy.

General Guidelines for General Guidelines for Prescribing Systemic DrugsPrescribing Systemic Drugs

Know the Drug (Drug Dependent Factors)Know the Drug (Drug Dependent Factors)IndicationsIndicationsAdverse DrugAdverse Drug--Patient Interactions (Properties of the Drug)Patient Interactions (Properties of the Drug)DrugDrug--Drug interactions (Properties of Other Drugs)Drug interactions (Properties of Other Drugs)DosageDosage

Administration RoutesAdministration RoutesAdministration AmountsAdministration Amounts

Know the Patient (Patient Dependent)Know the Patient (Patient Dependent)Monitor the TherapyMonitor the Therapy

General Guidelines for General Guidelines for Prescribing Systemic DrugsPrescribing Systemic Drugs

Know the Drug (Drug Dependent Factors)Know the Drug (Drug Dependent Factors)Know the Patient (Patient Dependent)Know the Patient (Patient Dependent)

Drug HistoryDrug HistoryMedical HistoryMedical HistoryKnown AllergiesKnown AllergiesPatient CharacteristicsPatient CharacteristicsHealth StatusHealth Status

Monitor the TherapyMonitor the Therapy

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General Guidelines for General Guidelines for Prescribing Systemic DrugsPrescribing Systemic Drugs

Know the Drug (Drug Dependent Factors)Know the Drug (Drug Dependent Factors)Know the Patient (Patient Dependent)Know the Patient (Patient Dependent)Monitor the TherapyMonitor the Therapy

Therapy EffectivenessTherapy EffectivenessPresence of Adverse EffectsPresence of Adverse EffectsPatient CompliancePatient Compliance

Major Nutritional StudiesMajor Nutritional StudiesEast Baltimore Eye StudyEast Baltimore Eye StudyBeaver Dam Eye StudyBeaver Dam Eye StudyChesapeake Bay WatermanChesapeake Bay Waterman’’s studys studyEye Disease Case Control Study *Eye Disease Case Control Study *Early Treatment Diabetic Retinopathy StudyEarly Treatment Diabetic Retinopathy StudyPhysicianPhysician’’s Health Study*s Health Study*NurseNurse’’s Study*s Study*AgeAge--Related Eye Disease StudyRelated Eye Disease Study

General overview of eye General overview of eye healthhealth

Dry EyesDry EyesEssential fatty acids (1,500 mg/day) derived from evening primrose, borage or black currant seed, combined with vitamin B6 (50­75 mg/day) and vitamin C (375­1,000 mg/day), have been shown to improve tear production and provide symptomatic relief

Help reduce inflammation by up-regulating PGE1 productionHave an effect on the way the esters and esterols are converted into cholesterols and overall lipid profile.

Dry EyesDry Eyes

Essential Fatty acidsEssential Fatty acidsHelp reduce inflammation by Help reduce inflammation by upregulatingupregulatingPGE1 productionPGE1 productionHave an effect on the way the esters and Have an effect on the way the esters and esterolsesterols are converted into cholesterols and are converted into cholesterols and overall lipid profile.overall lipid profile.

CataractsCataractsDevelopmental TheoriesDevelopmental Theories

EExposure to UV followed by accompanying oxidation xposure to UV followed by accompanying oxidation process.process.

slowed by a diet rich in antioxidants, specifically, Vitamin C.slowed by a diet rich in antioxidants, specifically, Vitamin C.GlucoseGlucose→→ SorbitolSorbitolيي+H2O2 (+H2O2 (aldosealdose reductasereductase reaction)reaction)

H2O2 H2O2 →→H2O+OH2O+OO causes damage to cell membranesO causes damage to cell membranes

Seddon et al. The Use of Vitamin Supplements and the Risk of Cataract among US Male Physicians. Am J Pub Health 1994

CataractsCataractsCan we prevent or reverse cataracts?Can we prevent or reverse cataracts?

Nutrition/SupplementationNutrition/SupplementationFlavenoidsFlavenoids, alpha , alpha lipoiclipoic acids and acids and VitmainVitmain C scavenge the free OC scavenge the free O

CataractousCataractous lens have 1/10th the vitamin C and 1/5lens have 1/10th the vitamin C and 1/5thth the the glutathioneglutathioneLuteinLutein intakes of approximately 6 mg per day also seem to intakes of approximately 6 mg per day also seem to provide protectionprovide protection

Lifestyle changesLifestyle changesSmokingSmoking

50% higher compared to non smokers50% higher compared to non smokersIncrease in lipidsIncrease in lipids

SunlightSunlight ExposureExposureAlcoholic ConsumptionAlcoholic Consumption

2X risk (> 7 drinks/week)2X risk (> 7 drinks/week)Photosensitizing drugsPhotosensitizing drugs

American Journal of Clinical NutritionAmerican Journal of Clinical Nutrition165 women consumed vitamin C (average 294 mg daily)165 women consumed vitamin C (average 294 mg daily)136 women did not (average 77 mg daily)136 women did not (average 77 mg daily)+C group (10 yrs)+C group (10 yrs)

77 percent lower prevalence of early or immature cataracts77 percent lower prevalence of early or immature cataracts83 percent lower prevalence of moderate cataracts83 percent lower prevalence of moderate cataracts

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Glaucoma (IOP)Glaucoma (IOP)Exercise:Exercise:

One study: Regular aerobic exercise on an exercise bike One study: Regular aerobic exercise on an exercise bike lowered the average IOP in glaucoma suspects by 4lowered the average IOP in glaucoma suspects by 4--1/2 1/2 mm, or about 20%mm, or about 20%PDSPDS

Effects of Diet on IOP:Effects of Diet on IOP:DHA/DHA/GinkoGinko——improve circulationimprove circulationLow salt, Low fat, low protein, hi Low salt, Low fat, low protein, hi carbcarb diet= reduction of diet= reduction of 55--7 mm7 mmIn animal studies, researchers were able to lower ocular In animal studies, researchers were able to lower ocular fluid pressure by injecting a very large dose of 0.2 fluid pressure by injecting a very large dose of 0.2 mLmL/day /day cod liver oil. Reduction was from 21 mmHg to 18, with cod liver oil. Reduction was from 21 mmHg to 18, with injections of 1 injections of 1 mLmL/day lowering pressure to 14.5 mmHg/day lowering pressure to 14.5 mmHgLuteinLutein and and zeaxanthinzeaxanthin also help protect the optic nerve. also help protect the optic nerve. Lack of Lack of luteinlutein in this nerve bundle may be an early sign of in this nerve bundle may be an early sign of glaucomaglaucoma

Glaucoma (ONH)Glaucoma (ONH)Glaucoma patients: abnormally high concentration of ONH Glaucoma patients: abnormally high concentration of ONH glutamate in the optic nerveglutamate in the optic nerveGlutamate is a primary chemical used in the transmission Glutamate is a primary chemical used in the transmission of optic nerve impulsesof optic nerve impulses

If cell death small amounts of glutamate may overwhelm the If cell death small amounts of glutamate may overwhelm the Muller cells and destroy surrounding cellsMuller cells and destroy surrounding cells

Accelerated loss of vision as observed in end stage glaucomaAccelerated loss of vision as observed in end stage glaucomaArray of natural nerve protectors may be able to minimize Array of natural nerve protectors may be able to minimize glutamate toxicityglutamate toxicity

Vitamin B12 (Vitamin B12 (methylcobalaminmethylcobalamin))Preserves Myelin, nerve insulatorPreserves Myelin, nerve insulator

<18 <18 SAMeSAMe (S(S--adenosylmethionineadenosylmethionine))ginkgo (ginkgo (Ginkgo Ginkgo bilobabiloba))vitamin Evitamin ECoenzyme Q10Coenzyme Q10folic acidfolic acidmagnesiummagnesium

Seddon et al., Dietary Carotenoids, Vitamins A,C, and E and Advanced Age-Related Macular Degeneration, JAMA 1994

– Multicenter case control prospective enrolling 35-80 M,F.– 356 case subjects, 530 age and sex control subjects, risk controlled– Higher dietary intake of caratenoids (leutin and azenthacin) was associated with a 43% lower risk for ARMD. Intake of preformed vitamin A was not related to ARMD.– Increasing the concentration of foods with certain carotenoids may decrease the risk of developing advanced or exudative AMD.

A study published in the August 2001 issue of Archives of Ophthalmologyfound that omega-6 fatty acids were associated with an increased risk of advanced ARMD, but that omega-3 fatty acids protected against it (as long as LA intake was low)

Macular DegenerationMacular DegenerationAREDS (AgeAREDS (Age--Related Eye Disease Study)Related Eye Disease Study)

Showed to a statistically significant degree Showed to a statistically significant degree that the intake of vitamins protects the that the intake of vitamins protects the progress of moderate to advanced ARMD in progress of moderate to advanced ARMD in 25% of patients25% of patients

C (500mg)C (500mg)E (400IU)E (400IU)beta carotene (15mg)beta carotene (15mg)MineralsMinerals

copper (2mg)copper (2mg)zinc (80mg) zinc (80mg)

Study does not apply to patients who Study does not apply to patients who have no signs of macular degeneration or have no signs of macular degeneration or who have early forms of the diseasewho have early forms of the diseaseLuteinLutein was not used in this study.was not used in this study.

AgeAge--Related Eye Disease Study Related Eye Disease Study (AREDS)(AREDS)

Study Cohort:Study Cohort:4,757 participants, 554,757 participants, 55--80 years of age, in 80 years of age, in 11 clinical centers nationwide. 11 clinical centers nationwide. Participants were given one of four Participants were given one of four treatments:treatments:

1) zinc alone1) zinc alone2) antioxidants alone;2) antioxidants alone;3) a combination of antioxidants and zinc; or 3) a combination of antioxidants and zinc; or 4) a placebo, a harmless substance that has no 4) a placebo, a harmless substance that has no medical effectmedical effect

AgeAge--Related Eye Disease Study Related Eye Disease Study (AREDS)(AREDS)

Study Cohort:Study Cohort:The three stages of AMD analyzed in this study The three stages of AMD analyzed in this study are:are:

Early AMDEarly AMD:: People with early AMD have, in one or both People with early AMD have, in one or both eyes, either several small drusen or a few mediumeyes, either several small drusen or a few medium--sized sized drusen; no vision loss. drusen; no vision loss. Intermediate AMDIntermediate AMD: Have, in one or both eyes, either : Have, in one or both eyes, either many mediummany medium--sized drusen or one or more large drusen; sized drusen or one or more large drusen; usually little or no vision loss. usually little or no vision loss. Advanced AMDAdvanced AMD: In addition to drusen, people with : In addition to drusen, people with advanced AMD have, in one or both eyes, either: advanced AMD have, in one or both eyes, either:

A breakdown of lightA breakdown of light--sensitive cells and supporting tissue in the sensitive cells and supporting tissue in the central retinal area (advanced dry form); or central retinal area (advanced dry form); or Abnormal and fragile blood vessels under the retina that can leaAbnormal and fragile blood vessels under the retina that can leak k fluid or bleed (wet form).fluid or bleed (wet form).

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AgeAge--Related Eye Disease Study Related Eye Disease Study (AREDS)(AREDS)

ResultsResultsAdvanced AMD in both eyesAdvanced AMD in both eyes

Supplements reduces the risk of vision loss about 25%Supplements reduces the risk of vision loss about 25%Intermediate AMD, or advanced AMD in one eye but not the other Intermediate AMD, or advanced AMD in one eye but not the other eyeeye

Supplements reduced the risk of vision loss by about 19 percent.Supplements reduced the risk of vision loss by about 19 percent.Study participants who had either no AMD or early AMD, the Study participants who had either no AMD or early AMD, the supplements didnsupplements didn’’t provide an apparent benefit.t provide an apparent benefit.

Antioxidants plus zinc group:Antioxidants plus zinc group: lowest risk of developing advanced lowest risk of developing advanced stages of AMD and its accompanying visual loss. stages of AMD and its accompanying visual loss. Zinc alone or "antioxidant alone" groupsZinc alone or "antioxidant alone" groups: Reduced their risk of : Reduced their risk of developing advanced AMD, but at more moderate rates compared developing advanced AMD, but at more moderate rates compared to the "antioxidants plus zinc group. to the "antioxidants plus zinc group. Placebo group: Highest risk of developing advanced AMD.Placebo group: Highest risk of developing advanced AMD.

Cautionary Notes:Cautionary Notes: Not a cure or restore vision already lostNot a cure or restore vision already lost

No significant effect on the development or progression of No significant effect on the development or progression of cataract.cataract.

RecommendationsRecommendationsNutritionNutrition

5 -9 servings of vegetables and fruits dailyDrink 8-10 glasses of water a day3 servings of 100% whole grains each day2 servings of fish per week Eat less cholesterol and saturated fats.

Avoid hydrogenated and trans fatty acid foods (man made fats)Eliminate deep fat fried foods, monosodium glutanate (MSG)Olestra impairs the absorption of carotenoids

RecommendationsRecommendationsSupplementsSupplements

A daily multivitaminA daily multivitamin66--9 9 ugsugs of B12of B12Folic acid 800 mcg Folic acid 800 mcg Thiamin (B6) 2 mgThiamin (B6) 2 mg400 IU of vitamin D400 IU of vitamin DVitamin E (400 IU/day)Vitamin E (400 IU/day)Vitamin C 250 mg Vitamin C 250 mg BetaBeta--Carotene 5,000 IU Carotene 5,000 IU LuteinLutein 10 mg 10 mg ZeaxanthinZeaxanthin 500 mcg500 mcg

2000 Mixed omega2000 Mixed omega’’ss1000 Vitamin C1000 Vitamin CCo QCo Q--1010

Zinc 25 mgZinc 25 mgSelenium 100 mcg Selenium 100 mcg Calcium 500 mg Calcium 500 mg Alpha Alpha LipoicLipoic Acid 100 mg Acid 100 mg NN--Acetyl Acetyl CysteineCysteine 100 mg100 mg

RecommendationsRecommendationsBasic NutrientsBasic Nutrients

Protein (30Protein (30--40%)40%)Adults (1Adults (1--1.5 g/lb)1.5 g/lb)Children (1.5Children (1.5--2 g/lbs)2 g/lbs)Babies (3 g/lb)Babies (3 g/lb)

Fat (15Fat (15--25%)25%)CarbsCarbs (40(40--50%)50%)

Lifestyle RecommendationsLifestyle Recommendations

Don’t’sSmoking

StopDecreases life expectancy between smokers and non-smokers differs by 18 years!

One cigarette destroys 25-100 mg of vitamin C!

AlcoholLimit your alcohol consumption to 1 glass of red wine at night. Alcohol interferes with liver functions, reducing protective glutathione levels (Alcohol 1993;10;469-75).One cocktail causes depletion of vitamins B1, B6, glutathione and folic acid!

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Lifestyle RecommendationsLifestyle RecommendationsDon’t’s

FoodAvoid fried foods, processed foods, sugary foods, and foods high in sodiumFood is Fuel-PERIOD

Caffeine*Reduce or eliminate drinking caffeine and sodas

Lifestyle RecommendationsLifestyle RecommendationsDODO’’ss

Get a physicalBPCholesterol (HDL, LDL, cholesterol/HDL ratio)Limit medications

OBC can interfere with the availability of vitamins B6, B12, folic acid, and vitamin C!Aspirin can triple the rate of excretion of your vitamin C!

Lifestyle RecommendationsLifestyle RecommendationsDODO’’ss

ExerciseExercise daily - 20 minutes daily aerobic exerciseSpend some time in the sun

Emotional/Spiritual healthMeditation, yoga, tai chi, prayer

The Only Important RuleThe Only Important RuleIt is Never Too Late to StartIt is Never Too Late to Start