This study aimed at assessing the associations of dietary fat with the risk of age-related maculopathy (ARM), in the framework of a population-based study from southern France. Nutritional data were collected using a dietitian-administered food-frequency questionnaire. ARM was classified from retinal photographs using the international classification and included neovascular age-related macular degeneration, geographic atrophy, soft indistinct drusen, soft distinct drusen associated with pigmentary abnormalities. After multivariate adjustment, high total, saturated and monounsaturated fat intake were associated with increased risk for ARM (odds ratio (OR)=4.74, P=0.007; OR=2.70, P=0.04; and OR= 3.50, P=0.03, respectively). Total polyunsaturated fatty acid was not significantly associated with ARM. Total and white fish intake was not significantly associated with ARM, but fatty fish intake (more than once a month versus less than once a month) was associated with a 60% reduction in risk for ARM (OR=0.42, P=0.01).
Although age-related maculopathy (ARM) is the leading cause of blindness in industrialized countries (Resnikoff et al., 2004), its pathogenesis remains unclear. Clearly identified risk factors are smoking (Klein et al., 2004) and the polymorphism of the genes of apolipoprotein E (Baird et al., 2004; Zareparsi et al., 2004) and Complement Factor H (Donoso et al., 2006), pointing, respectively, to the implication of lipid metabolism and inflammation in the etiology of ARM. In animal models, a high-fat diet, combined with human variants of apolipoproteins, leads to retinal lesions similar to those observed in ARM (Espinosa-Heidmann et al., 2004; Malek et al., 2005). Besides, the human retina is rich in ω3 polyunsaturated fatty acids (PUFA), and in particular in docosohexaenoic acid (DHA) which may play an important structural and protective role in the macula (SanGiovanni and Chew, 2005). DHA is mainly provided by fish and seafood.
Epidemiological data on the associations between dietary fat and ARM are scarce and partly inconsistent (Mares Perlman et al., 1995; Smith et al., 2000; Cho et al., 2001; Heuberger et al., 2001; Seddon et al., 2001, 2003). In the present study, we assessed the relationships of dietary fat and fish intake with the risk of ARM, in a population-based study from southern France.
The POLA (Pathologies Oculaires Liées à l'Age) study is a population-based study, aiming at the identification of the risk factors of cataract and ARM (Delcourt et al., 1998). Briefly, from 1995 to 1997, 2584 subjects aged 60 years or more were recruited from the population of Sète, a harbour on the French Mediterranean. In 1998–2000, 1947 of 2452 survivors (79.4%) participated in a follow-up ocular examination.
In 2002–2003, surviving participants aged 70 years or more were invited to participate in a dietary survey (POLANUT Study). Of the 1393 survivors, 832 (59.7%) participated in the POLANUT study. Nutritional data were collected using a validated food frequency questionnaire consisting of 165 items and a validated set of photographs for the estimations of portions (Daures et al., 2000). The interview was conducted by trained dieticians and lasted 45–60 min. There were three questions for fish: frequency and quantity of consumption of white fish (fresh cod, sole, whiting, etc.), fatty ‘blue’ fish (fresh tuna, canned tuna without oil, mackerel, sardine, salmon, etc.) and fatty fish canned in oil (tuna, sardine, anchovy). The last two questions were grouped for the estimation of fatty fish intake.
In the present study, ARM status was assessed from the retinal photographs taken at the follow-up examination (1998–2000) and graded according to the International Classification (Bird et al., 1995). Late ARM was defined by the presence of neovascular age-related macular degeneration or geographic atrophy. Early ARM was defined by the presence of soft indistinct drusen (>125 μm) and/or soft distinct drusen (>125 μm) associated with pigmentary abnormalities (hyper- or hypopigmentation), in the absence of AMD (Delcourt et al., 2005). Of the 832 subjects who participated in the dietary survey, we excluded 20 subjects (2.4%) with total energy intake lower than 3300 kJ/day or above 12500 kJ/day. Of the 812 remaining subjects, 701 (86.3%) had gradable photographs and data for adjustment variables, of which 10 (12 eyes) were with late ARM and 38 (46 eyes) with early ARM.
Because of the small number of subjects with late ARM, we pooled early and late ARM in all statistical analyses. For dietary fats, we first calculated energy-adjusted intake, using the residuals method developed by Willett (1998). We then determined the 20th and 80th percentile values, which formed three groups (low quintile, middle quintile, high quintile). To take into account data from both eyes and their correlation, we used logistic generalized estimating equations models for all analyses.
After adjustment for age and gender, risk of ARM was increased in subjects with high intake of total and monounsaturated fat (P (for trend)=0. 008 and 0.02, respectively), and tended to be increased in those with high saturated fat intake (P (for trend)=0.06). Total PUFA intake was not significantly associated with ARM (Table 1). Further adjustment for body mass index, smoking and self-reported cardiovascular disease did not materially affect the results. Further adjustment on total fat considerably attenuated the associations of monounsaturated and saturated fat with the risk of ARM.
Concerning fish intake, total fish intake was not significantly associated with ARM, neither were white fish or other sea foods (Table 2). After full multivariate adjustment, including total fat intake, fatty fish tended to be associated with a reduced risk of ARM, with an odds ratio of 0.26 (95% confidence interval: 0.11–0.64) for intake lower than 10 g/day and 0.64 (0.31–1.30) for intake greater than 10 g/day, by comparison with subjects reporting no intake of fatty fish (less than once a month). The multivariate-adjusted odds ratio for these two categories combined, corresponding to intake of fatty fish more than once a month compared to less than once a month, was 0.42 (95% confidence interval: 0.21–0.83, P=0.01).
High total fat intake has been associated with increased risk for ARM in two prospective studies (Cho et al., 2001; Seddon et al., 2003), whereas there was a trend which did not reach statistical significance in four cross-sectional or case–control studies (Mares Perlman et al., 1995; Smith et al., 2000; Heuberger et al., 2001; Seddon et al., 2001). In all four studies distinguishing the types of fat, high MUFA intake was associated with increased risk for ARM, whereas other types of fat gave inconsistent results (Smith et al., 2000; Cho et al., 2001; Seddon et al., 2001, 2003). Associations with ω3 PUFA, EPA and DHA or fish intake were generally consistent with a modest risk reduction for high intakes (odds ratios ranging from 0.4 to 0.9 across studies), but reached statistical significance only in two studies (Smith et al., 2000; Cho et al., 2001), illustrating the limitations of food data relative to ω3 PUFA . Similar to the present study, in the study by Cho et al., reduction in risk for ARM was mainly associated with intake of canned tuna, a main component of fatty fish intake.
Limitations of the present study include dietary assessment performed 3 years after retinal photography; impossibility to separate early and late ARM in statistical analyses because of small number of subjects; and low statistical power, in particular for the detection of modest risk reduction.
In conclusion, our study is consistent with increased risk of ARM in subjects with high fat, and in particular high MUFA, intake. The risk for ARM was reduced in subjects consuming fatty fish more than once a month.
Baird PN, Guida E, Chu DT, Vu HT, Guymer RH (2004). The epsilon2 and epsilon4 alleles of the apolipoprotein gene are associated with age-related macular degeneration. Invest Ophthalmol Vis Sci 45, 1311–1315.
Bird AC, Bressler NM, Bressler SB, Chisholm IH, Coscas G, Davis MD et al. (1995). An international classification and grading system for age-related maculopathy and age-related macular degeneration. The International ARM Epidemiological Study Group. Surv Ophthalmol 39, 367–374.
Cho E, Hung S, Willett WC, Spiegelman D, Rimm EB, Seddon JM et al. (2001). Prospective study of dietary fat and the risk of age-related macular degeneration. Am J Clin Nutr 73, 209–218.
Daures JP, Gerber M, Scali J, Astre C, Bonifacj C, Kaaks R (2000). Validation of a food-frequency questionnaire using multiple-day records and biochemical markers: application of the triads method. J Epidemiol Biostat 5, 109–115.
Delcourt C, Diaz JL, Ponton-sanchez A, Papoz L, The Pola Study Group (1998). Smoking and age-related macular degeneration: the POLA study. Arch Ophthalmol 116, 1031–1035.
Delcourt C, Lacroux A, Carriere I, Group PS (2005). The three-year incidence of age-related macular degeneration: the ‘Pathologies Oculaires Liees a l’Age' (POLA) Prospective Study. Am J Ophthalmol 140, 924–926.
Donoso LA, Kim D, Frost A, Callahan A, Hageman G (2006). The role of inflammation in the pathogenesis of age-related macular degeneration. Surv Ophthalmol 51, 137–152.
Espinosa-Heidmann DG, Sall J, Hernandez EP, Cousins SW (2004). Basal laminar deposit formation in APO B100 transgenic mice: complex interactions between dietary fat, blue light, and vitamin E. Invest Ophthalmol Vis Sci 45, 260–266.
Heuberger RA, Mares Perlman JA, Klein R, Klein BE, Millen AE, Palta M (2001). Relationship of dietary fat to age-related maculopathy in the Third National Health and Nutrition Examination Survey. Arch Ophthalmol 119, 1833–1838.
Klein R, Peto T, Bird A, Vannewkirk MR (2004). The epidemiology of age-related macular degeneration. Am J Ophthalmol 137, 486–495.
Malek G, Johnson LV, Mace BE, Saloupis P, Schmechel DE, Rickman DW et al. (2005). Apolipoprotein E allele-dependent pathogenesis: a model for age-related retinal degeneration. Proc Natl Acad Sci USA 102, 11900–11905.
Mares Perlman JA, Brady WE, Klein R, Vandenlangenberg GM, Klein BE, Palta M (1995). Dietary fat and age-related maculopathy. Arch Ophthalmol 113, 743–748.
Resnikoff S, Pascolini D, Etya'ale D, Kocur I, Pararajasegaram R, Pokharel GP et al. (2004). Global data on visual impairment in the year 2002. Bull World Health Organ 82, 844–851.
SanGiovanni JP, Chew EY (2005). The role of omega-3 long-chain polyunsaturated fatty acids in health and disease of the retina. Prog Retin Eye Res 24, 87–138.
Seddon JM, Cote J, Rosner B (2003). Progression of age-related macular degeneration: association with dietary fat, transunsaturated fat, nuts, and fish intake. Arch Ophthalmol 121, 1728–1737.
Seddon JM, Rosner B, Sperduto RD, Yannuzzi L, Haller JA, Blair NP et al. (2001). Dietary fat and risk for advanced age-related macular degeneration. Arch Ophthalmol 119, 1191–1199.
Smith W, Mitchell P, Leeder SR (2000). Dietary fat and fish intake and age-related maculopathy. Arch Ophthalmol 118, 401–404.
Willett W (1998). Nutritional Epidemiology. Oxford University Press: New York.
Zareparsi S, Reddick AC, Branham KE, Moore KB, Jessup L, Thoms S et al. (2004). Association of apolipoprotein E alleles with susceptibility to age-related macular degeneration in a large cohort from a single center. Invest Ophthalmol Vis Sci 45, 1306–1310.
This study was supported by the Institut National de la Santé et de la Recherche Médicale, Paris, France; by grants from the Fondation de France, Department of Epidemiology of Ageing, Paris, the Fondation pour la Recherche Médicale, Paris, the Région Languedoc-Roussillon, Montpellier, France and the Association Retina-France, Toulouse; and by financial support from Rhônes Poulenc, Essilor and Specia, and the Centre de Recherche et d'Information Nutritionnelle, Paris.
Guarantor: C Delcourt.
Contributors: CD designed and managed the study and wrote the first draft. IC performed the data management and carried out the statistical analysis. AL managed the data collection. MG provided the nutritional questionnaire and participated in the study design and data analysis. J-PC participated in the study design and data analysis and interpretation. All authors were involved in writing the final draft of the manuscript.
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Delcourt, C., Carrière, I., Cristol, JP. et al. Dietary fat and the risk of age-related maculopathy: the POLANUT Study. Eur J Clin Nutr 61, 1341–1344 (2007). https://doi.org/10.1038/sj.ejcn.1602685
- age-related maculopathy
- dietary fat
- unsaturated fats
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