During the early 1990s eye health as a nutraceutical category was in its infancy, overshadowed by other "major" health issues such as heart disease and cancer. Since then, particularly within the past two years, the eye health category has exploded.

According to a 2001 survey conducted by Sloan Trends and Solutions, Escondido, CA, 81% of consumers surveyed said eye health was their number one health concern, edging out both heart disease and cancer.

Dr. Mitchell May, CEO of camu camu supplier Synergy Production Laboratories, Moab, UT, commented on the surge in eye health concerns among consumers. "We are a very visually oriented species. Many people probably dread losing their sight more than they dread death," he said, adding, "The connections between eye health and nutrition are pretty straightforward and not nearly as complex and variable as with health issues such as cancer."


Eye Health Statistics
According to the most recent report released by the National Eye Institute (NEI), Bethesda, MD, in partnership with Prevent Blindness America, more than one million Americans age 40 and older suffer from blindness today and an additional 2.4 million are visually impaired. These numbers are expected to double in the next few decades as the baby boomer generation ages and life expectancy rates increase. As people get older, their risk of developing a number of age-related blinding diseases increases. The Vision Problems in the U.S., which represents the most comprehensive data available on the prevalence of eye disease in America, stated that the leading causes of vision problems and blindness are diabetic retinopathy, age-related macular degeneration (AMD), cataract and glaucoma.

As the aging baby boomers continue to experience problems with their eyesight, more people are becoming aware of these debilitating conditions. Growing evidence in the form of clinical studies that have been conducted to support the claims of eye health ingredients such as lutein, zeaxanthin, bilberry, vitamin C and astaxanthin suggests that in many cases vision impairment can be prevented with regular and proper supplementation. As a result, consumers are catching on and a recurrent theme throughout the industry is that there is tremendous potential for continued growth.


Lutein & Zeaxanthin: A Perfect Pair
When it comes to eye health lutein and zeaxanthin are often found coupled together. The reason is, not only do they usually occur together in the same food sources like spinach, kale and broccoli, but they are also present in the macular region of the eye.

Dr. Robert Abel, clinical professor of ophthalmology, Thomas Jefferson University, Philadelphia, PA, and author of The Eye Care Revolution, said lutein is the number one carotenoid found in the eye. Lutein, which is responsible for the bright yellow coloration of egg yolks, is also responsible for the macula's yellow pigment. "The reason that the macula, or center of the retina is called Macula lutea is because of lutein," he said.

The body does not synthesize lutein or zeaxanthin, so they must be delivered through the diet or supplements. "The eye is extremely vulnerable because the retina has a tremendous blood flow but the cornea and the lens have none, so it depends on remote nutrition," explained Dr. Abel. "People who take 6 mg of lutein or eat three cups of spinach a week have a certain significant risk reduction of macular degeneration."

Steve Hanson, marketing director, Kemin Foods, Des Moines, IA, which supplies FloraGLO® brand lutein, added that a review of the research suggests that the carotenoids lutein and zeaxanthin work in two ways. First, they filter out damaging ultraviolet blue light. Second, they protect against oxidative damage by quenching free radicals in the eye.

Expanding on the research was Lynda Doyle, director of marketing-new ingredients & business development, Roche Vitamins, Parsippany, NJ, which supplies vitamins E and C and beta-carotene, lutein and zeaxanthin. "Several lines of scientific evidence have associated higher dietary intakes of lutein and zeaxanthin with a reduced risk of AMD, the leading cause of acquired blindness in the U.S. elderly, and cataracts, the leading cause of blindness in the world," she said, adding, "Currently, a dietary gap exists in the U.S. between the 6 mg daily intake of lutein and zeaxanthin associated with a benefit and the actual dietary intake of these two carotenoids."

Ever since Kemin's FloraGLO® brand lutein was added to Wyeth Consumer Healthcare's Centrum® line, it has been the heavyweight champion, so to speak, in the eye health arena. Discussing this trend was Edward Lee, president, AIDP, City of Industry, CA, which supplies a range of eye health ingredients. "Following Centrum, more companies started adding lutein to their multivitamin formula. The sales of such multivitamins grew at over 10%, while plain multivitamin sales remained flat."

Dr. Abel concurred, "Lutein has come to such a level of recognition that it is now becoming mandatory. Over the past two years all of the companies that have added lutein have gone up in market share. The eye supplements that didn't have lutein went down in market share."

What keeps lutein at the top of the eye health category is the growing body of evidence that strongly suggests that it is the key nutrient that best-supports long term eye health. Mr. Hanson said, "New science continues to support the roles lutein and zeaxanthin play in diseases such as AMD and cataract."

With all of the hype surrounding lutein, its natural partner, zeaxanthin, is sometimes overlooked. According to the Vitamin Nutrition Information Service (VNIS), lutein and zeaxanthin were not measured independently in foods until quite recently. For this reason, many studies that have examined the association between age-related eye disease and nutritional status have reported on lutein and zeaxanthin together, not individually.

Mr. Lee feels zeaxanthin should not be overlooked. "Zeaxanthin is an ingredient equally important in preventing eye disorders," he said. "However, zeaxanthin was not commercially available two years ago when lutein was adopted by Centrum multivitamins." One of the reasons why zeaxanthin has remained in the shadows of lutein is because lutein is cheaper to refine, according to Mr. Lee. When prices become acceptable, zeaxanthin will be added to multivitamins in the next couple of years, he said.

Ms. Doyle expressed similar thoughts. "Vitamins E and C, beta-carotene and zinc have been eye health mainstay products-then lutein was introduced as the science broke," she explained. "But that same science supports zeaxanthin and the importance of zeaxanthin is becoming clearer as the science evolves. Zeaxanthin is going to be a key eye health nutrient going forward."

Kelly Moorehead, vice president of astaxanthin and spirulina supplier Cyanotech, Kailua-Kona, HI, supports the push toward a more widespread recognition of zeaxanthin's role in eye health and said the company's spirulina is exceptionally rich in zeaxanthin. "Most lutein/zeaxanthin dietary supplements contain only about 5% zeaxanthin," he said, adding, "Zeaxanthin has been shown to be nearly twice as strong as lutein in terms of singlet oxygen quenching, a measure of antioxidant strength. A typical three gram dose of Hawaiian spirulina supplies the equivalent carotenoid content of 100 grams of dark green leafy vegetables, in addition to other mixed carotenoids."

Another carotenoid that has been associated with eye health, but has received considerably far less attention than lutein and zeaxanthin is astaxanthin. It is found in many types of seafood, including lobster, shrimp and salmon and is what gives these sea creatures their pinkish color.

According to Mr. Moorehead, astaxanthin has been shown to be a more powerful antioxidant than both zeaxanthin or lutein. "One capsule of our BioAstin® natural astaxanthin product provides the equivalent of half a pound of salmon," he said. "One of the key features of astaxanthin is its ability to readily cross the blood-brain barrier and enter the eyes and central nervous system."

Up to this point there are no human clinical studies on astaxanthin but Mr. Moorehead said, it has been shown in animal research to concentrate in the macula and reduce photo bleaching of the retina during exposure to high intensity light.


Not Just Vitamin C
It has been know for a long time that vitamin C is an essential nutrient that plays multiple roles in human health, and is most often regarded as a major player. According to the VNIS, there are logical reasons to suspect that vitamin C plays a role in eye health. First, the antioxidant properties of vitamin C may be useful in protecting the lens. Second, the concentration of vitamin C in the lens is strikingly high when compared to other parts of the body.

Dr. Able explained, "The second highest level of vitamin C in the body is in the lens of the eye. Vitamin C helps build the collagen fibers that are in the lens and helps protect the lens. There have been many studies over the years that demonstrate the protection against cataracts with vitamin C at as little as 300 mg daily."

Dr. Phil Brown, Ester-C® product manager, Inter-Cal Corporation, Prescott, AZ explained that vitamin C is a premier water-soluble antioxidant that works well in the eye because of the high volume of liquid found there. "For so many years Ester-C, an efficiently absorbed form of vitamin C, has been sold to help with cold and flu," he said. "Now as more studies are coming out talking about the benefits of vitamin C in eye health, people are beginning to realize that this is also a nutrient that should be part of an eye supplement. It is one of the key free radical scavenging ingredients."

Roche's Ms Doyle discussed recent research examining both vitamin C and E, as well as other nutrients. "Antioxidant vitamins C and E have been associated with a reduced risk of cataracts in several studies and more recently have been shown to reduce the risk of late stage AMD, along with beta-carotene and zinc in the Age Related Eye Diseases Study (AREDS)," she explained. The results of the seven-year AREDS study were released last October and concluded that people at high risk of developing advanced stages of AMD lowered their risk by approximately 25% when taking a combination of santioxidants including vitamins E and C, beta-carotene and zinc, according to Ms. Doyle. "In addition, to reducing the development of advanced stages of AMD, the antioxidant nutrients also reduced the risk of vision loss caused by advanced AMD by 19% in the high risk group," she added.

Another ingredient that has become a player in the vitamin C arena is the camu camu berry. Dr. May explained that Synergy Labs' wild crafted camu camu concentrate is harvested deep within the rainforest by the indigenous peoples of Brazil using non-invasive, ancient practices. The difference between camu camu and traditional vitamin C supplements is that camu camu is a natural, whole food complex, not synthetic. Dr. May explained, "We do not spike our camu camu with isolated ascorbic acid and the benefits of this are obvious. The consumer receives a complex whole-food vitamin C that contains all the naturally occurring co-factors and phytonutrients that support and enhance the efficacy of the vitamin C."

According to the company, one gram of Synergized Camu Camu™ provides 200 mg of potent, complex vitamin C, with its naturally-occurring bioflavonoids and anthocyanins. Dr. May went on to say, "Many studies over the years have suggested that it is not simply the ascorbic acid that creates the numerous health benefits we associate with vitamin C, but rather the combined action of naturally occurring ascorbic acid with its naturally occurring co-factors, such as bioflavonoids. Nutrition is much more complex than isolated, synthetic nutrients. It is the synergy of all compounds found in whole foods that has supported human health since the beginning of time."


Bilberries & Blueberries
While the camu camu berry may be new to the eye health category, the bilberry is certainly no stranger. Bilberry's cousin, the blueberry, has even begun to hit the radar screen as well. If lutein and zeaxanthin have clinical science behind them, blueberries and bilberries have a long history on their side.

Thomas Payne, market development, North American Blueberry Council, San Francisco, CA, discussed the history behind blueberries and bilberries in relation to eye health. "For decades bilberries and blueberries have been associated with eye health and good vision, mainly in folk medicine and ethno botanical information from Europe and North America," he said. "Our North American native blueberries include Vaccinium corymbosum (highbush or cultivated), Vaccinium ashei for southern (rabbiteye) varieties and Vaccinium angustifolium or (lowbush) or what are called 'wild' blueberries. The European cousin of the North American blueberry is Vaccinium myrtillus or what are called bilberries."

According to bilberry supplier, Linnea, Locarno, Switzerland, the medicinal properties of bilberries have been known since the Middle Ages. However, the most common story associated with bilberries dates back to World War II.

The Blueberry Council's Mr. Payne expanded on this. "When British Royal Air Force pilots were on nighttime bombing missions they reported that their sight was improved after eating bilberry jam," he said. "This report initiated the first laboratory and clinical research in the 1960s into the effects of bilberry fruit extracts on the eyes and on the wider subject of the whole vascular system."

Discussing science further was Robin Ward, marketing manager for Linnea. "Studies have demonstrated that bilberry extract may act to improve visual function by increasing rhodopsin regeneration and favorably modifying several enzymatic parameters involved in retina damage. It is also believed that by speeding the regeneration of rhodopsin-the purple pigment that is used by the rods in the eye for night vision-that bilberry may help alleviate 'night blindness,'" he said. "The bilberry may also support microcirculation in the eye, thus promoting overall eye health and reducing eye strain."

Mr. Payne echoed these thoughts. He said, "The most effective medicinal use for bilberry/blueberry extract appears to be for improving microcirculation, thus its effects on the capillaries serving the eyes and the mucous membranes of the digestive and pulmonary systems."

The key to the beneficial effects of bilberries and blueberries are the anthocyanosides, which are derived from organic chemicals contained in the skin and give the Vaccinium fruit its color. At least 15 different anthocyanoside compounds have been identified from bilberry extracts. In addition, there are up to 7% tannins, several alkaloids, twelve different phenolic acids and three glycosides, which may all play a positive role in medicinal benefit.

Bilberry and blueberry consumption for eye health has been well documented around the world. Further, consumers are very familiar with both berries as they relate to eye health. In Japan, a mature market for blueberries, the recognition of blueberries is much more widespread, according to Mr. Payne. "In Japan we recorded more than 85% awareness of the relationship between blueberries and improved eyesight. However, in the U.S. the blueberries' relationship to eyesight has been much slower to evolve even though the anthocyanin in the bilberry is the same substance that is contained in the North American blueberry," said Mr. Payne.

While bilberries and blueberries are on the rise in the U.S., they still lag behind lutein and zeaxanthin. This is due in large part to the gap in the number of clinical studies for each ingredient. According to Mr. Payne, "There are more then 100 studies on the relationship between bilberries and the benefits of anthocyanins but with the blueberry, few such studies have been performed."


Consumer Awareness
On the consumer awareness front, most industry sources agree that the eye health category has grown tremendously over the past five years, particulary for lutein. Kemin's Mr. Hanson said, "In 1999 American Home Products' added FloraGLO lutein to Centrum® and Centrum Silver®-the first new ingredients to be added in over a decade-and turned up the volume on lutein discussion. The result has been a rapid growth in lutein awareness among U.S. consumers. In November 1999, only 5% of consumers had heard of lutein. Today, 44% of consumers say they've heard of lutein."

Holger Becker, Ph.D., business manager for beta-carotene, lutein esters and vitamin E producer, Cognis Nutrition and Health, LaGrange, IL, offered, "The eye health category hasn't grown, it's soared! According to recent IRI data, lutein is the only dietary supplement experiencing triple-digit growth. The percentage of unit sales change from 2000 to 2001 was 148%. The percentage of unit sales change from 1999 to 2001 was a whopping 3,024%."

This growth doesn't appear to be slowing any time soon. According to the 2000 U.S. Census, the 40+ population will grow by 7.8% between 2001-2005. In contrast, the under 40 population will only grow by 0.3% during that same period. Because most eye diseases affect the older population, this means that the market will continue to grow.

Mr. Hanson said physicians will start to play a bigger role. "Eye doctors will become more comfortable in recommending nutritional supplements to a higher percentage of patients," he said. "Currently, lutein supplements are recommended by 84% of all eye care professionals."

Bob Walker, vice president, sales and marketing handling for eye health ingredient supplier Pharmline, Lawrenceville, NJ, added, "As eye specialists and health professionals continue recommending supplements as a nutritional or preventative approach to eye disease, the market will take off," he said.

Synergy Labs' Dr. May noted, "Eye health is at the beginning of its growth curve. The first wave of baby boomers have only now reached an age where eye health is a concern. We can expect to see this category expand rapidly in the next five years."


Trends & Concerns
Since the body cannot synthesize the nutrients it needs most to ward off eye disease, and since the vast majority of the public does not eat enough fruits and vegetables, supplementation is necessary for optimal eye health.

In terms of supplements, many industry insiders feel that combination products will be the way to go. Katie Ferren, marketing director, Optipure, Los Angeles, CA, which supplies a range of eye health ingredients, commented, "I believe combination products are an effective way of targeting many of the different concerns that individuals have about eye health. By incorporating several different ingredients a person can take one pill for macualr degeneration, night vision, etc."

Inter-Cal's Dr. Brown agreed. "What is going to happen is you're going to see some of the mainstream companies coming out with more specific recommendations. They're going to be supplements, but what I would like to see is synergistic combinations of ingredients," he said. "A combination makes sense. The trend will be to intelligently formulate combinations that have been clinically proven to support vision health."

At the present time most nutrients for eye health are being delivered in pill form but the future for these nutrients in functional food formulations looks promising, according to Dr. May. "Consumers are tired of swallowing pills. Baby boomers with a greater awareness of natural health want 'real' food. Functional foods targeting the eye health market have enormous potential," he said.

However, Dr. Brown expressed some skepticism about the move towards functional foods. "I still worry a little about functional foods because I've seen there are too many products where there is more function on the label than there is in the food. A lot of companies are marketing functionality, however, they're not manufacturing functionality," he said. "Supplements are still the key way to do it because they are more targeted and provide the most controlled level of nutrients, which is going to give the most benefit."

While most industry experts have expressed an extremely optimistic attitude about the future of the eye health market, there is a lot of concern about proper dosages and poor quality ingredients. Todd Norton, president and COO, Sabinsa, Piscataway, NJ, makers of ZeaLutein®, explained, "In the case of lutein, it is pretty well documented that a minimum daily dose of 6-8 mg is recommended to provide eye health benefits. However, there are dietary supplements on the market that contain a fraction of the efficacious dose. The dose of lutein contained in such products is often nothing more than 'fairy dust' and to suggest or imply to consumers that such a dose will benefit them is misleading."

Kathleen Moran, market segment manager, dietary supplements, Cognis Nutrition and Health concurred. "One area that needs to be improved is the amount of nutrients used in some supplements," she said. "Study findings suggest reasonable amounts of a nutrient that are needed to achieve a health benefit, yet some manufacturers use amounts far smaller. This can foster mistrust with consumers, especially when products are promoted using misleading advertising."

Ultimately the fate of the eye health category is in the industry's hands, according to Mr. Hanson. "The only thing we can do to hurt the industry is to make wild, unsubstantiated claims about eye health supplements; reduce the quality of supplements, eye formulas and/or multivitamins by including less nutrients than the label claims or by substituting inferior products and trying to pass them off," he commented.

In the end, AIDP's Mr. Lee noted, "There is no pharmaceutical product (though development is under way) for preventing eye disease. This offers the supplement industry a unique opportunity."