Macular Degeneration and Diet

Dr. Chris Knobbe, an ophthalmologist, has written an excellent book — “Ancestral Dietary Strategy to Prevent and Treat Macular Degeneration” — which, like the title suggests, tells you how to address the most common cause of legal blindness in the United States.

One of his heroes is Weston A. Price, the dentist who wrote the classic book “Nutrition and Physical Degeneration.” I did not know this when I read Knobbe’s book, but it is very clear to me that Knobbe is the 21st century equivalent of Dr. Price.

The difference is that Price focused on the teeth and general physical degenerative diseases, like arthritis and cancer, whereas Knobbe is concentrated on his specialty, the eyes. But their findings are nearly identical: Industrially processed food is the root of most chronic disease. The first chapter is available free of charge on cureamd.org, where you can also order the book. Knobbe says,

“Ultimately … the next step I want to do is to … physically go out into the world and evaluate … the few niches around the world that are still consuming ancestral diets and analyze their macular degeneration,” he says.

Still, without venturing into foreign lands, Knobbe has amassed a wealth of knowledge by sifting through the published research, and what he’s found is shocking. Physicians are taught that macular degeneration is an inevitable consequence of aging and genetics, primarily, and has always existed. This, it turns out, is an absolute untruth.

Westernized diets are synonymous with chronic disease

As for so many others, Knobbe’s interest in diet and nutrition grew out of a personal experience. He’d suffered with arthritis for 15 years when he heard of the paleo diet, and within 10 days of switching saw significant improvement in his symptoms.

“In a nutshell, in about eight or 10 days, my arthritis was 80% better. This was so incredibly shocking to me after suffering for 15 years that I really wanted to know all I could know about nutrition. It just changed my life. I started investigating then.

This was in 2011. For the next couple of years, I investigated nutrition as much as I could. I learned so much but I was lost, until I came across the research of Weston Price …

Price was a highly-accomplished scientist, researcher and dentist who, in the 1930s, spent the better part of that decade evaluating people all around the world … as they transitioned from native, traditional diets to westernized diets …

He defined [the western diet] as refined white flour, sugars, canned goods, sweets, confectionery and vegetable oils. What Price found was that as people transitioned to those foods, they began to develop all of these diseases of civilization …

The take-home point here is that native, traditional foods contained 10 times as many fat-soluble vitamins, which are vitamins A, D and K2, four times as many water-soluble vitamins, which are all the B vitamins and C … and one and a half to 60 times more minerals than did the American diets of his day …

I’ve simplified it down to refined white flour, sugars, polyunsaturated vegetable oils and trans fats. When we consume these foods, we develop … chronic non-communicable disease. This includes heart disease, cancers, stroke, [high blood pressure], Type 2 diabetes, obesity, all the autoimmune disorders and so forth.

I understood this in 2013. Later that year, it finally hit me. I asked myself, ‘Could macular degeneration be another one of these diseases?’ Might it be a disease that follows processed food consumption? That question changed the course of my life …

I left ophthalmology practice and pursued this full-time, because I felt like it was the only way that I could … do all the research, write a book and publish papers … to try to get the word out … that our research supports the hypothesis with every last detail.”

Macular degeneration is not a natural part of aging

The amount of work Knobbe has put into his book is truly extraordinary. For starters, he did a complete historical analysis of macular degeneration, reviewing ophthalmology textbooks from more than 100 years ago. As mentioned, the orthodox, conventional view taught in medical school is that macular degeneration is a disease driven by aging and genetics.

According to Knobbe, 52 gene variants — single-nucleotide polymorphisms or SNPs — have been linked to macular degeneration. Smoking, obesity and lack of exercise are also thought to play a modest role. “Of course, with the hypothesis that was in my mind, I questioned that,” Knobbe says.

“I knew that if I was going to be able to draw connections between Westernized diet and macular degeneration, the first thing I needed to do is to go back and explore all the history of macular degeneration.

Honestly, I thought that I would be able to go onto PubMed or Google Scholar and I would find some excellent reviews and some papers that had covered this.

There was nothing of the sort. In early 2015, I spent three or four months doing nothing but trying to research the history of this, because I couldn’t find any kind of review that had ever been done of this.”

Here’s a quick summary of some of the history he discovered:

Medical books published over the following decades, all the way up to 1940, contained little or no mention of macular degeneration. Sir Stewart Duke-Elder was the world’s most esteemed and published ophthalmologist from approximately the 1920s to 1970.

In Duke-Elder’s 1927 textbook, there was no mention of macular degeneration at all. But in his 1940 second edition textbook, macular degeneration was given 13 pages. Here, Duke-Elder referred to it as “a common cause of failure in central vision in old people.”

“In 1927, I don’t think he even knew what macular degeneration was, which was typical. By 1940, it was becoming common,” Knobbe says. “By 1975, in the U.S., we had the Framingham study. At that point, 8.8% of Americans over the age of 52 had macular degeneration and 27.9% of those over the age of 75 had macular degeneration.

If you do the math, that translates to about 4.5 million Americans affected with macular degeneration. If you look back 50 years previous to 1925, there was no more than about 50 cases of macular degeneration in all of the world’s literature.”

Now, let me just say that ophthalmologists, their first kneejerk reaction to this is, ‘Well, they weren’t looking.’ I’m telling you, they say that because they haven’t read these textbooks. If you look at these textbooks from the 19th century, these clinicians were extraordinary.

Their attention to detail makes ours look pathetic because they didn’t have magnetic resonance imaging. They didn’t have optical coherence tomography scans like we use, fundus cameras and fluorescein angiography. They didn’t have any of that. They had an ophthalmoscope and they had their eyes. They did extraordinary exams … It [was] just an extraordinarily rare disease.”

According to Knobbe, in 2020 there will be 196 million people with macular degeneration, and it’s expected to increase to 288 million by 2040. As of 2006, 3.15 million people worldwide were legally blind in both eyes due to it. “I did the math and it turns out that in this world, at least 270 people will go blind every single day due to macular degeneration,” he says.

Prevalence parallels other chronic diseases

Knobbe’s research also shows macular degeneration is strongly associated with heart disease, Type 2 diabetes, obesity and metabolic syndrome. “If we look at what’s happened with those diseases historically, they all run parallel,” he says.

Take heart disease for example. Knobbe cites a 2012 study that looked at the history of all these chronic diseases over the last 200 years. In Boston, 942 people died in 1811, and not a single death was attributed to the heart, although there were 25 sudden deaths. Even if they were heart related, that’s still only 2.65%.

“There was, to the best of my ability to tell — and I’ve read a number of reviews — about eight cases of heart attack, myocardial infarction [and] coronary thrombosis in the entire 19th century,” Knobbe says.

In 1897, the famous physician Sir William Osler, one of the founding partners of Johns Hopkins Medical Center in Baltimore, published a paper in which he reviewed his previous 21 years of hospital experience.

He noted six cases of angina, chest pain that might be cardiac, but not a single MI [myocardial infarction or “heart attack”] in that 21 years. In 1910, he gave a lecture in London in which he reviewed the next 13 years of his career. Between 1897 and 1910, he’d seen 208 cases of angina, but still no heart attacks. The first confirmed case of heart attack in the U.S. was described in a 1912 paper by Dr. James Herrick.

“Nobody took him seriously,” Knobbe says. “In fact, this was ignored for about a decade. It wasn’t until the 1920s they started taking this seriously, because by the 1920s and 1930s, we started getting heart attacks. It’s just like macular degeneration …

If we fast-forward to 2010, what we have is 32.3% of the population dying of heart disease in the U.S. We went from extraordinary rarity in the 1800s to the leading cause of death, taking 1 out of 3 lives with heart disease in that timeframe.”

It’s all about diet

Knobbe summarizes the key dietary changes starting in the 1880s up to today, a primary one being the introduction of processed oils. Another is the introduction of refined flour.

“Today, 20% of the world’s diet is wheat. In the U.S., 85% of that is refined, meaning, it’s nutrient-deficient, kind of like sugar in a lot of ways. If you advance to 2009, those four foods — sugar, refined white wheat flour, polyunsaturated vegetable oils and trans fats — make up 63% of the American diet. This is the recipe for disaster. This is what sits at the base of all of this metabolic disease, including macular degeneration.”

According to Knobbe, industrially processed vegetable oils and seed oils are probably the most pernicious, as they cause significant oxidative stress, and actually get embedded into your cellular membranes. “I believe polyunsaturated vegetable oils are sheer danger. [They] are the most dangerous things in our food supply,” he says. Now, it’s important to realize that macular degeneration has a long incubation period. It doesn’t happen overnight.

“If a child is born today, his parents are consuming processed foods and the first thing he gets is processed food, he consumes that for 40 or 50 years, it takes that long before he has a heart attack, right? It’s very similar for macular degeneration,” Knobbe says.

“It’s the exact reason that we don’t have randomized-controlled clinical trials for heart disease and Alzheimer’s and macular degeneration, and there are never going to be, because you can’t control people’s diets very well in the first place and you certainly can’t control them for decades …

We looked at the data in 25 nations as it related to processed food consumption … If you look at Japan, for example … from 1974 to 1979 … their prevalence of macular degeneration was about 0.2%. Then 30 years later, in 2007, their prevalence of macular degeneration went to 11.4%. That is the most conservative number.

That shows their macular degeneration elevated 57fold in a 30-year period. Now, this cannot possibly be explained by aging or genetics. But when you look at the data, here’s what happened: their sugar consumption approximately doubled, but that wasn’t the big issue.

Here was the big issue: In 1961, they were consuming 9 grams per person per day of polyunsaturated vegetable oils. By 2000, they were up to 40 grams a day. Their vegetable oil consumption increased four-and-a-halffold … They started getting fast food restaurants and so forth. They started getting all of our processed foods.”

The same pattern is found in New Zealand, where prevalence of macular degeneration was 1.3% in 1967, and 10.3% in 2014 — an eightfold increase. Again, this radical increase parallels a massive increase in vegetable oil consumption. According to Knobbe, since he published his book in 2016 and started talking about this publicly, people are reporting their macular degeneration has stabilized or is getting better after following his recommendations, which in a nutshell boil down to:

• Avoiding processed foods, as most are loaded with harmful processed vegetable oils and added sugars
• Eating unprocessed whole food, including wild-caught seafood, organic grass fed beef, and pastured pork and fowl

What about supplements?

Classically, the two carotenoids recommended for retinal health are zeaxanthin and lutein. A more recent addition is astaxanthin, which is the most potent carotenoid antioxidant known.

The Age-Related Eye Disease Study¹ (AREDS), which began in the 1990s, specifically looked at vitamins and mineral supplements for age-related macular degeneration (AMD). The treatment group took vitamins C and E, beta-carotene and zinc for five years. As explained by Knobbe:

“In Stages 1 and 2 of macular degeneration, the earliest stages, there’s no benefit at all with the supplement. If you’re in Stage 3, which is moderate AMD in both eyes, or Stage 4, which is advanced AMD in one eye, 20% of that population went onto more advanced AMD over that five-year period …

In the control group that had moderate AMD or advanced AMD in one eye, 28% advanced to worse macular degeneration. The difference was 28% versus 20%. This means 8% of the subjects getting supplements were better off — 1 out of 13 people … [So] the number needed to treat is 13.

What people need to know is if they have moderately advanced AMD or advanced AMD in one eye and they take these supplements, there is a 1 in 13 chance they will benefit … All the studies show that you cannot prevent macular degeneration with supplements. There’s never been a study that showed that.

Then they did the AREDS 2 study.² In that study … they gave them the AREDS formula. They also gave omega-3 fatty acids and/or the carotenoids lutein and zeaxanthin. What they found in the primary analysis was that there was no benefit for the omega-3s and the carotenoids, the lutein and zeaxanthin. No benefit at all.

Then they went back and reanalyzed all the data again and determined that there was a slight benefit in favor of supplementing with lutein and zeaxanthin …

But … it’s really important to realize that there was other research done by Carl Awh and colleagues … They looked at genetics versus supplements. Without getting into the genetic component of it, what we realized is that potentially around 30% of patients taking the original AREDs formula will be worse off than if they didn’t take any supplements at all; 8% were better, but up to 30% could be worse.”

Now, much of this negative effect may be related to the specific vitamin formulations used. Synthetic vitamin E, for example, has been shown to cause potential problems, largely as a result of using high doses of a single isomer, the alphatocopherol and none of the tocotrienols. They may also have used synthetic carotenoids. Still, when you look at the evidence, your best bet is to address your daily food choices.

To protect your vision, eat an ancestral diet

As noted by Knobbe:

“I tell people that, really, this ancestral diet is … just about the simplest diet you could ever follow. You can make any kind of food you want, any type of ethnic food, whatever you want to eat. I don’t care if it’s steak or donuts. You can make those ancestrally if you eliminate those processed foods.

When people come to me and say, ‘Can I have Mexican food?’ or ‘Can I have Chinese food?’ Yes, yes. You can have all of those, but the only way to have them safely, generally, is to make them yourself, or to verify that they’re being made without polyunsaturated vegetable oils, without trans fat. Essentially try to minimize refined white flour [and] sugar.

If you do those things, I think you’re 95% of the way there, in terms of correcting your diet. I will say, it is not easy. If you don’t cook, if you don’t prepare your own meals, then I think you take a very serious risk, unless you know that your meals are being properly prepared without those kinds of components.”

Organ meats are an important part of the ancestral diet

Additionally, the ancestral approach stresses eating animals “from nose to tail,” meaning you don’t just want to eat steak, but also organs and connective tissue (think bone broth and the like).

Naturally, you’ll want to avoid animal products raised in concentrated animal feeding operations (CAFOs), as CAFO animals are not fed a natural diet but, rather, genetically engineered grains laced with antibiotics and other drugs. Ideally, look for 100% grass fed beef and animal products, certified by the American Grassfed Association (AGA).

If you’re eating muscle meat exclusively, you’re going to get relatively high levels of methionine, which could be problematic. That risk can be virtually eliminated by getting sufficient glycine from connective tissue.

“I couldn’t agree more,” Knobbe says. “I personally like to eat a lot of meat, but I’ve been consuming bone broth with added collagen now for a couple of years and just seem to be doing fabulous with that …

There’s absolutely no question in my mind — all the data supports this — that macular degeneration patients are vitamin A-, D- and K2-deficient. We can get those from organ meats, especially beef liver and chicken liver. Cod liver, fish liver oils are fantastic sources of vitamins A and D. So are the fish eggs, the roe.

For people who eat sushi, those are great sources of vitamins A and D. But for people who don’t eat liver at all, I really strongly recommend they consider an extra virgin cod liver oil supplement. You can take that, like a tablespoon, twice a week, and get great doses of vitamins A and D. Those are critical nutrients.”

Knobbe also agrees that sun exposure is an important component. Not only is it the ideal way to optimize your vitamin D, but sun exposure will also increase nitric oxide and improve ATP generation, and as noted by Knobbe, AMD is ultimately a disease process rooted in mitochondrial dysfunction.

More information

“One of the reasons I focus so strongly on macular degeneration is because it is heart-wrenching to see what happens to people who lose their vision … It is just tragic,” Knobbe says.

His book, “Ancestral Dietary Strategy to Prevent and Treat Macular Degeneration,” is a first-rate resource for anyone desiring to protect their vision into old age. Again, the book can be purchased (for the cost of printing) on cureamd.org, where you can also read the first chapter. The eBook can be downloaded for 50 cents.

I believe it would also be an invaluable reference for ophthalmologists everywhere, as the history of AMD — or more appropriately just macular degeneration, without the “age-related” designation — has never before been detailed as it is in this book. It’s a truly historic contribution to medicine. Sadly, it’s going to take personal initiative by doctors and patients to get this information out.

“Every single major ophthalmology organization, like the American Academy of Ophthalmology … the Retina World Conference, every single one of them turned us down,” Knobbe says. “They don’t want to hear it. Even after the published paper, they don’t want to hear this.

People become so invested in their own beliefs. It’s so hard for all these guys who have been believing, researching and telling their patients for three to four decades or more that this is a disease of aging and genetics. I think that’s a big part of it … The Christian Ophthalmology Society let me present to them this past summer. That’s the only big ophthalmology group I’ve presented to …

I think it’s very powerful evidence. One of the things that’s comforting to me is that this is what happened to so many people … Harold Ridley, who developed and put in the first intraocular lens in 1948 ... He was held in disregard and disdain for decades …”

Ultimately, an ancestral diet of real food not only can safeguard your vision, but also your heart, brain and general health. The same strategy will dramatically reduce your risk for cancer, heart disease, diabetes and Alzheimer’s, which are the biggest killers of our time.