22 August 2009
Regular yoga practice is associated with mindful eating, and people who eat mindfully are less likely to be obese, according to a study led by researchers at Fred Hutchinson Cancer Research Center.
The study was prompted by initial findings reported four years ago by Alan Kristal, Dr.P.H., and colleagues, who found that regular yoga practice may help prevent middle-age spread in normal-weight people and may promote weight loss in those who are overweight. At the time, the researchers suspected that the weight-loss effect had more to do with increased body awareness, specifically a sensitivity to hunger and satiety than the physical activity of yoga practice itself.
The follow-up study, published in the August issue of the Journal of the American Dietetic Association, confirms their initial hunch.
"In our earlier study, we found that middle-age people who practice yoga gained less weight over a 10-year period than those who did not. This was independent of physical activity and dietary patterns. We hypothesized that mindfulness – a skill learned either directly or indirectly through yoga – could affect eating behavior," said Kristal, associate head of the Cancer Prevention Program in the Public Health Sciences Division at the Hutchinson Center.
The researchers found that people who ate mindfully – those were aware of why they ate and stopped eating when full – weighed less than those who ate mindlessly, who ate when not hungry or in response to anxiety or depression. The researchers also found a strong association between yoga practice and mindful eating but found no association between other types of physical activity, such as walking or running, and mindful eating.
"These findings fit with our hypothesis that yoga increases mindfulness in eating and leads to less weight gain over time, independent of the physical activity aspect of yoga practice," said Kristal, who is also a professor of epidemiology at the University of Washington School of Public Health.
Kristal, a yoga enthusiast for the past 15 years, said that yoga cultivates mindfulness in a number of ways, such as being able to hold a challenging physical pose by observing the discomfort in a non-judgmental way, with an accepting, calm mind and focus on the breath. "This ability to be calm and observant during physical discomfort teaches how to maintain calm in other challenging situations, such as not eating more even when the food tastes good and not eating when you’re not hungry," he said.
To test whether yoga in fact increases mindfulness and mindful eating, Kristal and colleagues developed a Mindful Eating Questionnaire, a 28-item survey that measured a variety of factors:
disinhibition – eating even when full;
awareness – being aware of how food looks, tastes and smells;
external cues – eating in response to environmental cues, such as advertising;
emotional response – eating in response to sadness or stress; and
distraction – focusing on other things while eating.
Each question was graded on a scale of 1 to 4, in which higher scores signified more mindful eating. The questionnaire was administered to more than 300 people at Seattle-area yoga studios, fitness facilities and weight-loss programs, among other venues. More than 80 percent of the study participants were women, well-educated and Caucasian, with an average age of 42. Participants provided self-reported information on a number of factors, including weight, height, yoga practice, walking for exercise or transportation and other forms of moderate and strenuous exercise.
More than 40 percent of the participants practiced yoga more than an hour per week, 46 percent walked for exercise or transportation for at least 90 minutes per week and more than 50 percent engaged in more than 90 minutes of moderate and/or strenuous physical activity per week.
The average weight of the study participants was within the normal range – not surprising considering that the study sample intentionally consisted of people more physically active than the U.S. population in general. Body-mass index was lower among participants who practiced yoga as compared to those who did not (an average of 23.1 vs. 25.8, respectively).
Higher scores on the mindfulness questionnaire overall (and on each of the categories within the questionnaire) was associated with a lower BMI, which suggests that mindful eating may play an important role in long-term weight maintenance, Kristal said.
"Mindful eating is a skill that augments the usual approaches to weight loss, such as dieting, counting calories and limiting portion sizes. Adding yoga practice to a standard weight-loss program may make it more effective," said Kristal, who himself scored high on the mindful-eating survey and has a BMI within the normal range.
Moving forward, Kristal and colleagues suggest that their Mindful Eating Questionnaire, the first tool of its kind to characterize and measure mindful eating, may be useful both in clinical practice and research to understand and promote healthy dietary behavior.
"Beyond calories and diets, mindful eating takes a more holistic approach that can empower individuals to build positive relationships with food and eating, said first author Celia Framson, M.P.H., R.D., C.D., a former graduate student of Kristal's – and former yoga teacher – who now works with adolescents with eating disorders at Seattle Children's Hospital. "The Mindful Eating Questionnaire offers a new and relevant dimension for masuring the effectiveness of dietary behavior interventions. It also encourages nutrition and medical practitioners to consider the broad scope of behavior involved in healthy eating," she said.
ScienceDaily (Aug. 20, 2009) — New research at The University of Texas Health Science Center at Houston suggests that ancient Chinese herbal formulas used primarily for cardiovascular indications including heart disease may produce large amounts of artery-widening nitric oxide. Findings of the preclinical study by scientists in the university's Brown Foundation Institute of Molecular Medicine for the Prevention of Human Diseases (IMM) appear in the Sept. 15 print issue of the journal Free Radical Biology & Medicine.
Nitric oxide is crucial to the cardiovascular system because it signals the inner walls of blood vessels to relax, which facilitates the flow of blood through the heart and circulatory system. The messenger molecule also eliminates dangerous clots, lowers high blood pressure and reduces artery-clogging plaque formation.
The results from this study reveal that ancient Chinese herbal formulas "have profound nitric oxide bioactivity primarily through the enhancement of nitric oxide in the inner walls of blood vessels, but also through their ability to convert nitrite and nitrate into nitric oxide," said Nathan S. Bryan, Ph.D., the study's senior author and an IMM assistant professor.
Herbal formulas are a major component of traditional Chinese medicines (TCMs), which also include acupuncture and massage. "TCMs have provided leads to safe medications in cancer, cardiovascular disease and diabetes," said C. Thomas Caskey, M.D., IMM director and CEO. "The opportunity for Dr. Bryan's work is outstanding given that cardiac disease is the No. 1 cause of death in the United States."
In the study, researchers performed laboratory tests on DanShen, GuaLou and other herbs purchased at a Houston store to assess their ability to produce nitric oxide. Ancient Chinese herbal formulas used primarily for cardiovascular indications are made up of three to 25 herbs. The formulas can be administered as tablets, elixirs, soups and teas.
Most Chinese herbal formulas marketed in the United States are not considered drugs by the U.S. Food and Drug Administration, said Yong-Jian Geng, M.D., Ph.D., study co-author and cardiology professor at The University of Texas Medical School at Houston. They are considered dietary supplements and are not regulated as strictly as drugs.
Scientists also tested the capacity of the store-bought TCMs to widen blood vessels in an animal model. "Each of the TCMs tested in the assays relaxed vessels to various degrees," the authors stated.
"Further studies should be considered in humans, particularly those with cardiac indications," Geng said. "Hopefully, we will have more data to report in the near future."
While fully integrated into the healthcare systems in some parts of Asia, ancient Chinese herbal formulas are often considered alternative medicines in Western nations. Part of the reason, according to Bryan, may be that until recently little was known about how they work.
"The next step is to identify the active components of the TCMs that are responsible for producing the NO. We are currently trying to isolate and identify the active component or components," Bryan said.
Yaoping Tang, M.D., an IMM postdoctoral fellow, was the lead author of the study titled "Nitric oxide bioactivity of traditional Chinese medicines used for cardiovascular indications." Also collaborating on the study was Harsha Garg, an IMM senior research assistant.
Bryan is the editor of a new book titled "Food, Nutrition and the Nitric Oxide Pathway: Biochemistry and Bioactivity" published by DesTech Publishing and works in the IMM Center for Cell Signaling directed by Ferid Murad, M.D., Ph.D., who won the 1998 Nobel Prize in Physiology and Medicine for his work with nitric oxide as a signaling molecule in the cardiovascular system. Bryan and Geng are on the faculty of The University of Texas Graduate School of Biomedical Sciences at Houston.
20 August 2009
You may have heard recent news reports saying that researchers have identified a family with a genetic mutation that causes members to require only six hours sleep a night. However, that gene is vanishingly rare in humans, found in less than 3 percent of people.
So, almost all people who says they needs only six hours' sleep are deluding themselves. And the consequences of chronic sleep deprivation are serious -- sleep deprivation has been linked to an increase in motor vehicle accidents, deficiencies in short-term memory, focus and attention. It's also tied to depressed mood and a decrease in the ability to control appetite.
The only real answer is to sleep as much as your body actually needs.
19 August 2009
Researchers have found another reason to eat well: a healthy diet helps prevent kidney stones. Loading up on fruits, vegetables, nuts, low-fat dairy products, and whole grains, while limiting salt, red and processed meats, and sweetened beverages is an effective way to ward off kidney stones, according to a study appearing in an upcoming issue of the Journal of the American Society Nephrology (JASN). Because kidney stones are linked to higher rates of hypertension, diabetes, increased body weight, and other risk factors for heart disease, the findings have considerable health implications.
Eric Taylor, MD (Maine Medical Center) and his colleagues at Brigham and Women's Hospital conducted a large study to determine the effects of healthy eating habits on the formation of kidney stones. The investigators collected information from individuals enrolled in three clinical studies: the Health Professionals Follow-up Study (45,821 men followed for 18 years), the Nurses' Health Study I (94,108 older women followed for 18 years), and the Nurses' Health Study II (101,837 younger women followed for 14 years).
Dr. Taylor's team assigned a score to each participant based on eight components of a DASH (Dietary Approaches to Stop Hypertension) style diet: high intake of fruits, vegetables, nuts and legumes, low-fat dairy products, and whole grains and low intake of salt, sweetened beverages, and red and processed meats. Individuals with higher DASH scores consumed diets that were higher in calcium, potassium, magnesium, oxalate, and vitamin C and lower in sodium.
A total of 5,645 incident kidney stones developed in the participants in the three studies. In each study, participants with the highest DASH scores were between 40% and 45% less likely to develop kidney stones than participants with the lowest DASH scores. The reductions in kidney stone risk were independent of age, body size, fluid intake, and other factors.
Because a DASH-style diet may affect the development of hypertension, diabetes, and other chronic diseases associated with kidney stones, the researchers also performed an analysis limited to study participants without hypertension or diabetes. Even among those individuals the DASH diet reduced the risk of kidney stones.
Many of the medications used to treat kidney stones have unpleasant side effects. This study indicates that adopting a DASH-style diet may be an effective alternative.
The authors report no financial disclosures. Study co-authors include Teresa Fung (Simmons College) and Gary Curhan, MD (Brigham and Women's Hospital).
The article, entitled "DASH-Style Diet Associates with Reduced Risk for Kidney Stones," will appear online at http://jasn.asnjournals.org/ on August 13, 2009, doi 10.1681/ASN.2009030276.
The American Society of Nephrology (ASN) does not offer medical advice. All content in ASN publications is for informational purposes only, and is not intended to cover all possible uses, directions, precautions, drug interactions, or adverse effects. This content should not be used during a medical emergency or for the diagnosis or treatment of any medical condition. Please consult your doctor or other qualified health care provider if you have any questions about a medical condition, or before taking any drug, changing your diet or commencing or discontinuing any course of treatment. Do not ignore or delay obtaining professional medical advice because of information accessed through ASN. Call 911 or your doctor for all medical emergencies.
Founded in 1966, the American Society of Nephrology (ASN) is the world's largest professional society devoted to the study of kidney disease. Comprised of 11,000 physicians and scientists, ASN continues to promote expert patient care, to advance medical research, and to educate the renal community. ASN also informs policymakers about issues of importance to kidney doctors and their patients. ASN funds research, and through its world-renowned meetings and first-class publications, disseminates information and educational tools that empower physicians.
Eating chocolate can reduce heart attack survivors' risk of dying, say researchers who followed 1,169 Swedish men and women, ages 45 to 70, from the time they were hospitalized with their first heart attack in the early 1990s.
Those who ate chocolate two or more times a week were about three times less likely to die from heart disease than those who never ate chocolate, the study found. Smaller amounts of chocolate also offered some protection, Agence France Presse reported.
The study, which appears in the September issue of the Journal of Internal Medicine, is believed to be the first to demonstrate that chocolate can help prevent death in heart attack survivors.
"Our findings support increasing evidence that chocolate is a rich source of beneficial bioactive compounds," the researchers wrote.
Antioxidants in cocoa likely explain chocolate's beneficial effects in heart attack survivors
17 August 2009
New analysis could lead to heated debate among heart dictors over whether omega-3 polyunsaturated fatty acids deserves its own recommended daily intake levels.
a centuries-old pharmacy shelf fixture -- has recently been the subject of much research to determine its heart-protecting properties. Now, some cardiologists say it is time for omega-3 polyunsaturated fatty acids to join others nutrients for which a daily recommended intake has been established.
Dr. Carl Lavie, medical director of Cardiac Rehabilitation and Prevention at the Ochsner Heart and Vascular Institute in New Orleans, is one such cardiologist. He says that healthy people should consume at least 500 mg per day of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) in order to meet their daily needs for the nutrient.
Lavie and his colleagues made the recommendations in a paper released Monday in the Journal of the American College of Cardiology.
Those with known cardiovascular disease, the researchers added, should consume 800 to 1,000 mg per day of the nutrient.
Researchers have warned people to beware of the damage that acidic beverages have on teeth. Yet, for some, the damage and problems associated with drinking sodas, citric juices or certain tea may have already begun to take effect. The question remains: What can be done to restore teeth already affected?
In a recent study that appeared in the May/June 2009 issue of General Dentistry, the AGD's clinical, peer-reviewed journal, lead author, Mohamed A. Bassiouny, DMD, MSc., PhD, outlined the acidic content of beverages, such as soda; lemon, grapefruit and orange juice; green and black tea; and revealed three steps to rehabilitate teeth that suffer from dental erosion as a result of the excessive consumption of these products.
Dr. Bassiouny instructs those who are experiencing tooth erosion to first, identify the culprit source of erosion, possibly with the help of a dental professional. Then, the individual should determine and understand how this source affects the teeth in order to implement measures to control and prevent further damage. Lastly, the person should stop or reduce consumption of the suspected food or beverage to the absolute minimum. He notes that information about the acid content of commonly consumed foods or beverages is usually available online or on the product's label. It is also recommended to seek professional dental advice in order to possibly restore the damaged tissues.
"Dental erosion," according to Dr. Bassiouny, "is a demineralization process that affects hard dental tissues (such as enamel and dentin)." This process causes tooth structure to wear away due to the effects that acid has on teeth, which eventually leads to their breakdown. It can be triggered by consumption of carbonated beverages or citric juices with a low potential of hydrogen (pH), which measures the acidity of a substance. Excessive consumption of the acidic beverages over a prolonged period of time may pose a risk factor for dental health.
"Some may not even realize a problem exists when their teeth are in the early stages of dental erosion," says Kenton Ross, DDS, FAGD, a spokesperson for the AGD. "Without proper diagnosis by a general dentist, more serious oral health issues could occur."
"Visiting your general dentists twice a year can help maintain healthy teeth as well as uncover and prevent future problems," says Dr. Ross.
Your brain needs exercise just like a muscle. If you use it often and in the right ways, you will become a more skilled thinker and increase your ability to focus. Here are 5 simple techniques to exercise your brain.
1. Minimize Television Watching -- Watching television doesn’t use your mental capacity OR allow it to recharge. When you feel like relaxing, try reading a book instead. If you’re too tired, listen to some music. When you’re with your friends or family, leave the tube off and have a conversation.
2. Exercise -- Time spent exercising always leads to greater learning because it improves productivity during the time afterwards. Using your body clears your head and creates a wave of energy.
3. Read Challenging Books -- If you want to improve your thinking and writing ability you should read books that make you focus. Reading a classic novel can change your view of the world and will make you think in more precise, elegant English.
4. Early to Bed, Early to Rise -- Nothing makes it harder to concentrate than sleep deprivation. You’ll be most rejuvenated if you go to bed early and don’t sleep more than 8 hours.
5. Take Time to Reflect -- Spending some time alone in reflection gives you a chance organize your thoughts and prioritize your responsibilities. Afterwards, you’ll have a better understanding of what’s important and what isn’t.
The Public Health Agency of Canada (PHAC) has confirmed that it will be investigating the role of vitamin D in protection against swine flu, NutraIngredients-USA.com has learned.
The agency started a study last year on the role of vitamin D in severe seasonal influenza, which it said it will now adapt to the H1N1 swine flu virus.
“Researchers in PHAC are working with colleagues at McMaster University and with partners at other universities and hospitals to determine whether there is a correlation between severe disease and low vitamin D levels and/or a person's genetic make up. This line of research in seasonal influenza will be adapted to H1N1,” wrote the agency in an e-mail to NutraIngredients-USA.com.
PHAC said it is testing serum samples to examine this possibility in collaboration with colleagues at the University of Toronto.
Preventing ‘severe outcomes’
Part of the researchers’ goal is to understand if vitamin D levels are in any way responsible for the fact that most people with seasonal influenza develop a mild illness but a small minority go on to develop severe symptoms.
According to PHAC, results from its study will indicate the extent and nature of the role of vitamin D in sever seasonal influenza. The agency said it would most likely take at least three influenza seasons to be able to recruit a sufficient sample size of individuals with severe disease and controls before the results can be “meaningfully” analyzed.
“If we find that there is a correlation between severe disease and vitamin D levels we shall, with our partners in the future, conduct randomized controlled studies to determine the whether vitamin D can be used as a means to mitigate severe seasonal influenza,” it said.
“PHAC intends to adapt this strategy to H1N1 in order to prevent severe outcomes of infection.”
The agency stressed that the role of vitamin D in H1N1 is not well established. However, it added that early work in the 1940s, in experimental animal models, indicated that mice that receive diets low in vitamin D are more susceptible to experimental swine flu infection than those that receive adequate vitamin D (Young, 1946).
In addition, PHAC said that epidemiological evidence suggests a role for vitamin D in seasonal influenza in general.
“Influenza infection is correlated geographically and seasonally with levels of solar ultraviolet radiation (Cannell, 2006). Given that vitamin D is synthesisized in our skin on exposure to sunlight, low serum levels of 25(OH) vitamin D in winter months appear to correlate with the occurrence of seasonal influenza in the winter. However a direct causal relationship between low vitamin D levels and the risk of influenza remains to be proven.”
“How vitamin D might protect against influenza infection is not fully understood. However new research suggests that vitamin D induces the production of antimicrobial substances in the body that possess neutralizing activity against a variety of infectious agents including influenza virus (Doss, 2009).”
Researchers documented serious neuronal damage in rat brains following exposure to microwave radiation from a cell phone, at levels comparable to what people would experience during normal use.
Damage to nerve cells was observed in several places within the brain, including the cortex, hippocampus and basal ganglia. Exposed animals had "scattered and grouped dark neurons ... often shrunken .. with loss of internal cell structures."
According to the scientists, "intense use of mobile phones by youngsters is a serious consideration. A neuronal damage of the kind described here may not have immediate, demonstrable consequences, even if repeated. In the long run, however, it may result in reduced brain reserve capacity that might be unveiled by other later neuronal disease or even the wear and tear of aging."
The journal in which these results were published, Environmental Health Perspectives (the journal of the National Institute of Environmental Health Sciences), went so far as to recommend using headsets.
An article in Skeletal Radiology, a well-respected journal, created something of a sensation in Europe last year. It reported that researchers from Danube Hospital in Austria examined the knees of marathon runners using M.R.I. imaging, before and after the 1997 Vienna marathon. Ten years later, they scanned the same runners’ knees again. The results were striking. “No major new internal damage in the knee joints of marathon runners was found after a 10-year interval,” the researchers reported. Only one of the participants had a knee that was truly a mess, and he’d quit running before the 1997 marathon (but had been included in that study anyway). His 1997 knee M.R.I. revealed cartilage lesions, swelling and other abnormalities. In the years that followed, the knee became worse, showing augmented tissue damage and more serious lesions. His exam prompted the researchers to wonder whether he would have been better off persisting as a runner, because, as they speculate, “continuous exercise is protective, rather than destructive,” to knees.
You can’t be a runner past the age of 40, as I am, without hearing that running will ruin your knees, by which doomsayers usually mean that we’ll develop “degeneration of the cartilage in the kneecap, which reduces its shock-absorbing capacity,” says Ross Tucker, a physiologist in South Africa and co-author of the new book “The Runner’s Body: How the Latest Exercise Science Can Help You Run Stronger, Longer and Faster.” In other words, we’ll be afflicted with arthritis.
It’s not an unreasonable supposition; other sports have been linked with early-onset arthritis in knees. In a British study, almost half of the middle-aged, formerly elite soccer players were found to have crippling, bone-on-bone arthritis in at least one knee. Former weight lifters also have a high incidence of the condition, as do retired N.F.L. players.
But despite entrenched mythology to the contrary, runners don’t seem prone to degenerating knees. An important 2008 study, this one from Stanford University, followed middle-aged, longtime distance runners (not necessarily marathoners) for nearly 20 years, beginning in 1984, when most were in their 50s or 60s. At that time, 6.7 percent of the runners had creaky, mildly arthritic knees, while none of an age-matched control group did. After 20 years, however, the runners’ knees were healthier; only 20 percent showed arthritic changes, versus 32 percent of the control group’s knees. Barely 2 percent of the runners’ knees were severely arthritic, while almost 10 percent of the control group’s were. “We were quite surprised,” says Eliza Chakravarty, an assistant professor at the Stanford University School of Medicine and lead author of the study. “Our hypothesis going in had been that runners, because of the repetitive pounding, would develop more frequent and more severe arthritis.”
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Instead, recent evidence suggests that running may actually shield somewhat against arthritis, in part because the knee develops a kind of motion groove. A group of engineers and doctors at Stanford published a study in the February issue of The Journal of Bone and Joint Surgery that showed that by moving and loading your knee joint, as you do when walking or running, you “condition” your cartilage to the load. It grows accustomed to those particular movements. You can run for miles, decades, a lifetime, without harming it. But if this exquisite balance is disturbed, usually by an injury, the loading mechanisms shift, the moving parts of the knee are no longer in their accustomed alignment and a “degenerative pathway” seems to open. The cartilage, like an unbalanced tire, wears away. Pain, tissue disintegration and, eventually, arthritis can follow.
The Takeaway With Gretchen ReynoldsSo, the best way to ensure that your knees aren’t hurt by running is not to hurt them in the first place. “The biggest predictor of injury is previous injury,” Tucker says, and one of the best deterrents against a first (or subsequent) knee injury is targeted strength training. “The hip stabilizers, quads, hamstrings and core must all be strong enough. As soon as there is weakness, some other muscle or joint must take over, and that’s when injuries happen.”
If you’ve injured your knee in the past, particularly if you’ve ever torn an A.C.L. (an injury that, in the Stanford gait study, was closely associated with misalignment and cartilage degeneration), talk to your physician before running. But for most runners, the scientific observations of Chakravarty will ring true. “What struck me,” she says, “is that the runners we studied were still running, well into their 70s and 80s.” They weren’t running far, she says. They weren’t running frequently. They averaged perhaps 90 minutes a week. “But they were still running.”
A supplement containing lutein, zeaxanthin and blackcurrant extract may reverse signs of visual fatigue, according to a new study from Japan and Singapore.
Visual fatigue, caused by many factors, not least staring at computer monitors for long hours, may be eased a daily supplement containing blackcurrant fruit extract (200 mg), lutein (5 mg), and zeaxanthin (1 mg), according to a randomized, double-blind, placebo-controlled cross-over trial.
The findings, published in the journal Applied Ergonomics, adds to the ever growing body of science supporting the eye health benefits of lutein and zeaxanthin.
Lutein, a nutrient found in various foods including green leafy vegetables and egg yolk, has a ten-year history in the dietary supplement market as a nutrient to reduce the risk of age related macular degeneration (ADM). It is often used in combination with zeaxanthin.
The global lutein market is set to hit $124.5 million (€93 million) in 2013, according to a 2007 report from Frost & Sullivan.
According to the report, manufacturers need to address this growing maturity in dietary supplements by identifying new and potentially lucrative application segments that offer opportunities for the continued growth of the lutein market
Looking at visual fatigue
Researchers from Kwansei Gakuin University in Japan and Singapore's Cerebos Pacific Limited, which supplied the supplement used in the study, recruited 22 people to participate, 13 of whom actually completed the study.
The subjects were randomly assigned to receive either the lutein supplement, or placebo, for two weeks, followed by two weeks of washout, and a further two weeks with the opposite intervention.
After completing a two hour visual proof reading task, the researchers measured signs of visual fatigue, including so-called eye fixation related potentials (EFRP).
“EFRP is thought to reflect the total functioning of the visual system, consisting of the retina, the muscle of the pupil, the muscles involved in eye movements, and central nervous system functioning,” explained the researchers.
“In the present study, [a supplement containing lutein, zeaxanthin, and blackcurrant extract]may have had beneficial effects on visual functioning that served to counteract or prevent fatigue induced by the proof reading task,” they added.
“Overall, our results suggest that a combination of lutein, zeaxanthin and blackcurrant extract can aid recovery from visual fatigue,” they concluded.