JFO Open Opthalmology 3 (2023) 100036

Contents lists available at ScienceDirect

JFO Open Opthalmology

journal homepage: www.elsevier.com/locate/jfop

Reviews

Overlooked dietary insufficiencies impacting visual impairment: A systematic

review and meta-analysis
Katrina Domenica Cirone a , Daiana Roxana Pur a , Monali S. Malvankar-Mehta b,c, *
a
Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON, Canada
b
Department of Ophthalmology, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON, Canada
c
Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON, Canada

A R T I C L E I N F O A B S T R A C T

Keywords: Purpose: Malnourished individuals are at a higher risk of developing visual impairment. Dietary restrictions can
Dietary restrictions cause nutritional insufficiencies and negatively impact overall health. This review was performed to characterize the
Picky eating correlation between restrictions in dietary intake and various forms of visual impairment (VI) in adults.
Visual impairment
Methods: The CINAHL, EMBASE, MEDLINE, and PubMed databases were systematically searched through July 21,
Low vision
Macular degeneration
2022. Studies that investigated observed visual changes due to dietary restrictions and omission of dietary
Meta-analysis components were eligible for inclusion. Of the 2541 unique studies, 22 eligible studies underwent data extraction,
and 11 were incorporated into the quantitative meta-analysis.
Results: Meta-analysis identified that an adequate intake of fish (OR = 0.62; CI: [0.49–0.79]), and micronutrients
(OR = 0.49; CI: [0.25–0.96]) are positively correlated with a decreased odds of VI as indicated by the presence of
age-related macular degeneration, diabetic retinopathy, distance acuity, retinal acuity, age-related maculopathy,
cataract development, and dual sensory impairment among adults.
Conclusion: Overall, dietary restrictions and picky eating may be associated with unfavorable visual outcomes. These
outcomes may reduce quality of life, independence, mobility, and driving ability among adults. Findings suggest the
need for initiatives to encourage a healthy and balanced diet. Further education and instruction among healthcare
providers might be initiated to allow for recognition of dietary insufficiencies and their associated adverse outcomes
in order to reduce the possibility of developing severe and potentially irreversible consequences.

1. Introduction regardless of differences in various factors such as gross domestic product,

The epidemiological transition has resulted in an increased life
expectancy, which has consequently caused chronic non-communicable
diseases to become the primary reason for premature mortality globally
[1–5]. The World Health Organization has identified a poor diet and
physical inactivity as two significant risk factors responsible for this
increasing prevalence [6]. The correlation between a healthy diet and
general health has been thoroughly analyzed. A balanced diet has been
found to improve health and decrease the possibility of developing
chronic diseases and adverse health conditions [7]. As a result, dietary
reference intakes (DRIs) have been established to help individuals
achieve good health and decrease the likelihood of developing chronic
diseases. Despite these guidelines, many individuals consume a diet that
fails to meet the recommended DRIs for many nutrients, thus resulting in
various undesirable outcomes [8].
Visual impairment (VI) is a feature of various preventable chronic
conditions and is a significant problem faced by many adults globally
economic status, and existing healthcare programs; although these
factors do impact the prevalence [9]. For example, the Canadian
Longitudinal Study on Aging, has determined approximately 5.7% (95%
CI: 5.4–6.0) of Canadians between the ages 45 and 85 possess a form of VI
[10]. Various factors can contribute to an increased risk of VI such as
increased age and the associated cognitive, psychological, and social
changes that accompany aging, lower-income, smoking, the presence of
type 2 diabetes, and poor nutrition [11,12].
Diet is a variable known to influence visual function, and many studies
have attempted to identify the linkage between certain dietary
components and their resulting impact on vision [13,14]. Previous
studies have determined adults with VI often have an inadequate intake of
whole grains, lean meats, and dairy products [15]. Additional research
has observed that individuals diagnosed with ocular conditions such as
age-related macular degeneration (AMD) cataracts, and glaucoma may
lack a healthy diet, in addition to the information and understanding
needed to make the informed decisions necessary to promote optimal

* Corresponding author at: Ivey Eye Institute, St. Joseph's Hospital, 268, Grosvenor Street, London, Ontario N6A 4V2, Canada.
E-mail address: Monali.Malvankar@schulich.uwo.ca (M.S. Malvankar-Mehta).

http://doi.org/10.1016/j.jfop.2023.100036
Received 25 March 2023; Accepted 28 May 2023
Available online 15 June 2023
2949-8899/© 2023 The Authors. Published by Elsevier Masson SAS. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/).
K.D. Cirone
visual health [16–19]. Due to the observed relationship between VI and
diet, it is possible that picky eating can influence the change of developing
various visual disorders. Identifying the correlation between dietary
insufficiencies and VI is essential as this can help develop and guide
programs encouraging a balanced diet to achieve and maintain optimal
ocular function. This is paramount as vision loss is commonly
accompanied by a reduction in quality of life and various negative
outcomes such as reduced independence and mobility, and has been
linked to worsened mental health, cognitive function, educational
attainment, and social interactions [20]. In this study, we assessed and
quantitatively synthesized the available literature that analyzed the
linkage between limitations in dietary consumption and the presence of
VI within adults.
2. Methods
2.1. Search strategy
Study correspondence followed the standards outlined by the
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
guidelines (see Online Resource 1) [21]. A comprehensive review was
performed with Google scholar to define the scope, identify any gaps in
knowledge, and ensure the feasibility of the proposed systematic review.
The databases CINAHL, EMBASE, MEDLINE, and PubMed were
systematically searched to identify literature that reported a linkage
between dietary insufficiencies and visual impairments up until July 21,
2022. The PICOS criteria were used to curate a searchable query from the
research question (Table 1). A systematic search of each database was
performed (see Online Resource 2). This incorporated database specific
key words and MeSH terms such as “picky eating” (or “food fussiness”),
“preferences, food” (or “food selections”), “food nephobia”, “dietary
limitations”, “fatty acids”, “malnutrition”, “eye diseases” (or “eye
disorders”, “age-related macular degeneration”, “diabetic retinopathy”,
“cataract”), “vision disorders” (or “reduced vision”, “diminished vision”,
“vision disparity”, “low vision”, “nyctalopia”), “visual acuity”, “retinol”
(or “vitamin A”). Only studies written in English were included. No
limitations were placed on geographic location or publication date. To
optimize comprehensiveness, citation tracking of relevant articles and
systematic reviews was conducted. This review was registered on
PROSPERO, ID number CRD42021282698.
2.2. Eligibility criteria
Two reviewers (K.D.C. and D.R.P.) reviewed the studies detected by
the systematic search (Fig. 1). For inclusion, articles must be:
 a comparative, randomized controlled comparison, or a non-ran-
domized comparison study;
 the studies were conducted in humans participants with either normal
vision or an acquired VI;
 dietary factors should be assessed;
 the correlation between dietary components and vision must be listed
as an outcome.
In the cases where authors wrote about cohort studies repeatedly, each
study was required to assess a unique dietary component for inclusion.
Table 1
PICOS criteria for inclusion of studies.
Parameter Description
Population Human participants with normal vision or patients with visual impairment due to an acquired cause
Intervention Dietary components associated with picky eating such as fat intake, fish intake, fruit intake, milk intake, micronutrients, and total dietary assessment
Comparison The absence or presence of dietary components associated with picky eating
Outcomes Age-related macular degeneration, age-related maculopathy, cataract development, diabetic retinopathy, distance acuity, and retinal acuity
Study Comparative, randomized controlled comparison, or non-randomized comparisons (cohort studies, case-control studies, cross-sectional studies, prospective follow-up
design studies, retrospective studies, and multi-center studies)
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JFOP 3 (2023) 100036
Case studies or reports, commentaries, editorials, opinion studies
systematic reviews, and meta-analyses were excluded, as well as studies
that utilized non-human participants. Studies that solely assessed
individuals with food allergies, specialized diets (ketogenic diet, paleo,
vegan, vegetarian), or VI caused by a congenital or genetic cause were
excluded to reduce possible confounding. No restrictions were placed on
study location or follow-up.
2.3. Study selection
Studies identified via the systematic search were imported into
Covidence, a systematic review software, and screened by two reviewers
(K.D.C. and D.R.P.) independently [22]. A duplication check was
conducted by one reviewer (K.D.C.) to identify and remove duplicate
studies. The initial screen of article titles and abstracts included literature
that assessed visual function and changes associated with certain dietary
insufficiencies. Articles that included participants with specialized diets
and congenital vision conditions were excluded during the full-text
screen. Literature with inadequate detail was excluded.
After the title and abstract screen and full-text screen any disagree-
ments were resolved and Cohen's kappa coefficient was calculated; 0.38
and 0.64, respectively.
2.4. Quality assessment
To critically assess the quality of included literature, a 27-item Downs
and Black checklist was used (see Online Resources 3 and 4) [23].
Selected studies were evaluated on the method of reporting, validity
(external, bias, and confounding), and power. A score of 14 or below
indicates a poor-quality study, studies scoring within the range of 15 to 19
are of moderate quality, while studies scoring 20 or greater are considered
high quality. A minimum score of 15 was used as the inclusion cut-off.
2.5. Data extraction
One investigator (K.D.C.) abstracted the following items from
included studies: author(s), publication year, study design, location,
sample size, reported dietary factors, visual findings, the visual condition
detection method, various dietary alterations, and visual outcomes
associated with specific dietary factors. Further extracted data included
the odds ratio (OR), lower and upper limit, and P-value adjusted for age,
sex, and smoking status.
2.6. Meta-analysis
To complete the meta-analysis, STATA v. 15.0 was used. The primary
outcome of interest was the adjusted odds ratios (OR) for the risk of visual
impairment based on the consumption of fish, Omega-3 polyunsaturated
fatty acids (PUFA), monounsaturated fatty acids (MUFA), and micro-
nutrients. Results in the literature were adjusted for demographic
variables and varied among included articles. For binary, dichotomous, or
categorical outcomes, OR were computed as the treatment effect or effect
size. The fixed-effect or random-effects models were used to aggregate the
OR for each study. Heterogeneity was assessed by calculating I2 statistics,
Z-value, and x2 statistics. An I2 statistic below 30% implies low
K.D. Cirone
Fig. 1. PRISMA flowchart summarizing the results of the literature search.
heterogeneity thus requiring a fixed-effect computation while a higher I2
value indicates heterogeneity and necessitates use of a random-effects
model. Significant heterogeneity is suggested by a high Z-value, low P-
value (< 0.01), requiring that a random-effects model be computed.
Forest plots were created to illustrate study-specific effect sizes while
funnel plots were created to identify evidence of publication bias.
2.7. Main outcomes
This study assessed the impact of dietary limitations associated with
picky eating on vision. The impact of fish, omega-3 PUFA, MUFA, and
micronutrient intake were independently quantified.
3. Results
3.1. Search results
Following the systematic search, 2935 articles were identified; 268
from MEDLINE, 1104 from EMBASE, 153 from CINAHL, 811 from Web of
Science, 561 from PubMed, and 38 from citation tracking of eligible
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JFOP 3 (2023) 100036
articles (see Online Resource 1). After duplicate removal, 2541 were
screened. Following the initial screen, 52 articles progressed to full-text
screening after which 22 studies remained. These 22 studies underwent
qualitative synthesis and 11 of these studies were incorporated into the
meta-analysis. Fig. 1 summarizes the literature search.
3.2. Study characteristics
Table 2 outlines the relevant details of the 22 included studies
conducted globally. Ten studies utilized a cohort design, 8 were case-
control studies, and 4 were cross-sectional studies. Sample sizes were
between 138 and 38,903 participants. To assess diet, a food frequency
questionnaire was used in 91% (n = 20) of studies and a mixture of verbal
interviews (n = 1), 24-hour recall (n = 2), and a fasting blood draw
(n = 1) were used by the remaining studies. Fifty-nine percent (n = 13) of
studies investigated AMD while the remainder covered diabetic
retinopathy (DR) (n = 4), distance acuity (n = 2), retinal acuity
(n = 1), age-related maculopathy (ARM) (n = 1), cataract development
(n = 1), and dual sensory impairment (vision and hearing) (n = 1).
Detection of the reported visual condition was done by ophthalmologist
K.D. Cirone JFOP 3 (2023) 100036

Table 2
Characteristics of the included studies on association between diet and vision.
Author Year Design Location Sample size Method of dietary Visual condition Outcome assessment
(n) assessment

Mustafa and Daoud 2020 Cross- USA 5930 FFQ & 24 h dietary recall Cataracts Cataract extraction history
[24] sectional
Merle et al. [25] 2018 Cohort study France 38903 FFQ Distance acuity Ophthalmologist assessment
Alcubierre et al. [26] 2016 Case-control Spain 294 FFQ DR Ophthalmologist assessment
Aoki et al. [27] 2016 Case-control Japan 530 FFQ AMD Ophthalmologist assessment
Millen et al. [28] 2016 Cohort study USA 1339 FFQ & fasting blood draw DR Retinal photographs
Stevens et al. [29] 2015 Case-control UK 208 24 h dietary recall AMD Ophthalmologist assessment
Chiu et al. [30] 2014 Cross- USA 8103 FFQ AMD Retinal photographs
sectional
Tanaka et al. [31] 2013 Cohort study Japan 978 FFQ DR Ophthalmologist assessment
Berson et al. [32] 2012 Case-control Global 357 FFQ Distance acuity & retinal Ophthalmologist assessment
acuity
Ganesan et al. [33] 2012 Cross- India 1261 FFQ DR Retinal photographs
sectional
Chiu et al. [34] 2009 Case-control USA 2924 FFQ AMD Retinal photographs
Gopinath et al. [35] 2009 Cross- Australia 2443 FFQ DSI Ophthalmologist assessment
sectional
Parekh et al. [36] 2009 Cohort study USA 1787 FFQ AMD Stereoscopic fundus
photographs
SanGiovanni et al. 2009 Cohort study USA 1837 FFQ AMD Ophthalmologist assessment
[37]
Cho et al. [38] 2008 Cohort study Global 1115 FFQ AMD Ophthalmologist assessment
Chua et al. [39] 2006 Cohort study Australia 2335 FFQ ARM Retinal photographs
Seddon et al. [40] 2006 Case-control USA 681 FFQ AMD Ophthalmologist assessment
van Leeuwen et al. 2005 Cohort study Netherlands 4170 FFQ AMD Stereoscopic fundus
[41] photographs
Snellen et al. [42] 2002 Case-control Netherlands 138 Verbal interview AMD Ophthalmologist assessment
Cho et al. [43] 2001 Cohort study Global 567 FFQ AMD Ophthalmologist assessment
Seddon et al. [44] 2001 Cohort study USA 853 FFQ AMD Ophthalmologist assessment
Seddon et al. [45] 1994 Case-control USA 876 FFQ AMD Ophthalmologist assessment

USA: United States of America; UK: United Kingdom; FFQ: food frequency questionnaire; AMD: age-related macular degeneration; ARM: age-related maculopathy; DR:
diabetic retinopathy; DSI: dual sensory impairment (visual & auditory).

assessment in most studies (64%, n = 14), and the rest used retinal
photographs (n = 5), stereoscopic fundus photographs (n = 2), or
cataract extraction history (n = 1).
The impact of specific dietary components on the observed visual
findings is summarized in Table 3. Investigated dietary factors consisted
of fat intake (n = 10) which included total fat, vegetable fats, MUFA, oleic
acid, linolenic acid, omega-3 PUFA, and omega-6 PUFA, fish intake
(n = 4), total dietary assessment (n = 3), fiber intake (n = 1), fruit intake
(n = 2), milk intake (n = 1), dietary glycemic index (n = 1), specific
micronutrients (n = 7) which included a-tocopherol, vitamins ACDE,
b-carotene, carotenoids (lutein and zeaxanthin), and zinc.
3.3. Assessment of study quality
Appendices S3 and S4 provide an overview of study quality and risk of
bias. The quality analysis identified 36% (n = 8) of studies as possessing a
moderate quality (15–19) and the remaining 64% (n = 14) of studies
were designated as good quality (20–25). Based on this assessment, all 22
studies were included in the qualitative review.
3.4. Publication bias
In the funnel plot of the literature that assessed fish consumption
(Fig. 2), the studies are primarily located close to the top while one small
study is found in the lower left quadrant which indicates smaller studies
with non-significant results may not be published. Studies are located
from the bottom left to the middle right in the funnel plot looking at MUFA
consumption (Fig. 3) and in the funnel plot that assessed omega-3 PUFA
intake see (Fig. 4). The literature incorporated in the funnel plot for
micronutrient intake (Fig. 5) are scattered along the bottom of the plot. As
a result of the small sample and effect sizes, and the high heterogeneity of
included studies, publication bias could not be concluded. Further, funnel
plots are only one method to detect bias, and publication bias is just one
potential explanation for funnel plot asymmetry.
3.5. Fish consumption
Four studies (4436 participants) looked at the impact of fish
consumption and the development of visual deterioration evidenced
by either ARM or AMD. The forest plot for fish intake (Fig. 6) indicates the
odds ratio (OR) summary effect using the fixed-effect model, I2 value of
0.0% (P-value = 0.636). Participants with adequate fish intake had a low
risk of visual impairment compared to individuals who did not meet
recommended values with an OR of 0.62 [95% CI: 0.49–0.79]. Fig. 6
implies inadequate fish intake has a significant impact on the risk of
adverse visual outcomes.
3.6. Fat intake
Three studies (2934 participants) analyzed the impact of monounsat-
urated fatty acid intake (excluding supplements) on vision as evidenced
by AMD or DR. Fig. 7 displays the OR summary effect using the random-
effects model due to significant heterogeneity, I2 value of 82.0% (P-
value = 0.004). Participants with adequate MUFA intake had a non-
significant risk of visual impairment compared to those who did not meet
recommended values with an OR of 0.73 [95% CI: 0.27–1.94]. Fig. 7
suggests that inadequate monounsaturated fatty acid intake has a non-
significant impact on the risk of experiencing adverse visual outcomes.
The study conducted by Seddon et al. [44] was the only literature
included that did not show a decrease in the OR for visual impairment
with a diet consisting of greater MUFA intake.
Five studies (6186 participants) assessed the impact of omega-3 PUFA
intake (excluding supplements) on visual deterioration as evidenced by
either ARM or AMD. Fig. 8 illustrates the OR summary effect using the

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Table 3
Dietary factors and visual findings reported.
Author Analyzed dietary component Visual findings [OR (95% CI)]a

Mustafa and Daoud [24] Dietary milk intake Milk consumption does not appear to be associated with the development of age-related cataracts in the general
population 0.87 (0.75–0.99)
Merle et al. [25] Total dietary assessment A poor diet is associated with an increased risk of reduced visual acuity 1.37 (0.99–1.88)
Alcubierre et al. [26] Fat intake MUFA and oleic acid are both inversely related to the development of DR in adults with T2DM 0.42 (0.18–0.97)
Aoki et al. [27] Omega-3 PUFA, a-tocopherol, Low intakes of omega-3 PUFA, a-tocopherol, zinc, b-carotene, & vitamins D &C are all associated with
zinc, vitamin C, vitamin D, & neovascular AMD 0.20 (0.10–0.40)
b-carotene
Millen et al. [28] Vitamin D and fish oil supplements 25(OH)D concentrations  75 nmol/L were associated with lower odds of any retinopathy assessed 3 years later
0.39 (0.20–0.75)
Stevens et al. [29] Lutein/zeaxanthin intake Failure to meet the RDA for fiber, calcium, vitamin D & E, and caloric intake may be associated with AMD
development
Chiu et al. [30] Western vs. Oriental diet An Oriental dietary patternb may reduce the risk of AMD 0.73 (0.64–0.82) while a Western dietary patternc may
increase AMD risk 1.55 (1.31–1.83)
Tanaka et al. [31] Fruit intake The risk of DR decreases with an increased intake of fruits and vegetables, vitamin C, and b-carotene in diabetics
0.48 (0.32–0.71)
Berson et al. [32] Long-chain omega-3 PUFA Low omega-3 PUFA intake is associated with an increased risk of reduced distance & retinal acuity in adults with
retinitis pigmentosa
Ganesan et al. [33] Fiber intake Low-fibre intake is associated with in an increased presence of DR in diabetics 2.24 (1.01–5.02)
Chiu et al. [34] DHA, EPA, & glycemic index Enhanced intake of DHA & EPA, and reducing dietary glycemic index are protective against advanced AMD
progression 0.73 (0.57–0.94)
Gopinath et al. [35] Total dietary assessment A poor diet results in an increased risk of dual sensory impairment 2.62 (1.08–6.36)
Parekh et al. [36] Fat intake A high intake of omega 3 and 6 fatty acids are associated with an increased prevalence of AMD 1.80 (1.20–2.60)
while MUFA may decrease the risk 0.47 (0.20–1.00)
SanGiovanni et al. [37] Omega-3 PUFA Decreased omega-3 PUFA consumption is associated with an increased risk of neovascular AMD 0.65 (0.50–0.85)
Cho et al. [38] Lutein/zeaxanthin intake Lutein and zeaxanthin were found to be protective against AMD 0.72 (0.53–0.99)
Chua et al. [39] Omega-3 PUFA A diet high in omega-3 PUFA can be protective against early and late ARM 0.41 (0.22–0.75)
Seddon et al. [40] Omega-3 PUFA Dietary omega-3 PUFA and fish consumption reduce AMD risk 0.55 (0.32–0.95)
van Leeuwen et al. [41] Vitamins C & E, b-carotene, & zinc A high dietary intake of b-carotene, vitamins C & E, and zinc were associated with a substantially reduced risk of
AMD 0.65 (0.46–0.92)
Snellen et al. [42] Lutein intake AMD prevalence in patients with low antioxidant and lutein intake was approximately twice as high as that in
patients with high intake 2.40 (1.100–5.10)
Cho et al. [43] Fat intake Higher total fat intake is associated with an increased risk of AMD 0.65 (0.46–0.91)
Seddon et al. [44] Fat intake Higher vegetable fat, MUFA, PUFA, and linoleic acid consumption were associated with an elevated AMD risk 1.71
(1.00–2.94). Omega-3 PUFA 0.61 (0.26–1.42) and fish consumption both reduce AMD risk 0.60 (0.32–1.14)
Seddon et al. [45] Vitamins A, C, E, & carotenoids Foods high in carotenoids and vitamin A can decrease AMD risk 0.43 (0.20–0.70)

DHA: docosahexaenoic acid; EPA: eicosapentaenoic acid; PUFA: polyunsaturated fatty acids; MUFA: monounsaturated fatty acids; AMD: age-related macular
degeneration; ARM: age-related maculopathy; DR: diabetic retinopathy; RDA: recommended dietary allowance.
a
Values were adjusted for age, sex, and smoking status.
b
Oriental diet pattern is classified as a diet with a higher intake of vegetables, legumes, fruit, whole grains, tomatoes, and seafood.
c
Western diet pattern is classified as a diet with a higher intake of red meat, processed meat, high-fat dairy products, French fries, refined grains, and eggs.

random-effects model due to the existence of significant heterogeneity, I2
value of 89.7% (P-value = 0.000). Individuals with adequate omega-3
polyunsaturated fatty acid intake had a non-significant decreased risk of
visual impairment compared to those who didn’t meet recommended
values with an OR of 0.56 [95% CI: 0.25–1.27]. Fig. 4 suggests that
inadequate omega-3 PUFA intake has a non-significant impact on the risk
of experiencing adverse visual outcomes. The study conducted by Parekh
et al. [36] was the only study that did not show a low OR for visual
impairment with a diet consisting of greater omega-3 PUFA intake.
3.7. Micronutrient consumption
Four studies (3499 participants) assessed the impact of micronutrient
consumption and the development of visual dysfunction classified as
either AMD or DR. Fig. 9 shows the OR summary effect using the random-
effects model due to the existence of significant heterogeneity, I2 value of

Fig. 2. Funnel plot for included studies evaluating fish consumption and visual Fig. 3. Funnel plot for included studies evaluating monounsaturated fatty acid
deterioration. consumption and visual deterioration.

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K.D. Cirone JFOP 3 (2023) 100036

81.4% (P-value = 0.001). Individuals with adequate micronutrient

intake had a significantly decreased risk of visual impairment compared
to adults that did not meet recommended values with an OR of 0.49 [95%
CI: 0.25–0.96]. Fig. 9 suggests that inadequate micronutrient intake has a
significant impact on the risk of adverse visual outcomes.

4. Discussion

The present study assessed the relation between dietary insufficien-

Fig. 4. Funnel plot for included studies evaluating omega-3 polyunsaturated fatty
acid consumption and visual deterioration.
Fig. 5. Funnel plot for included studies evaluating micronutrient intake and visual
deterioration.
cies and visual deterioration. An evaluation of specific dietary
inadequacies was conducted with meta-analysis to assess their individual
effects.
Overall, this review determined diet and dietary limitations can
impact vision and result in the development of visual impairment. For a
diet consisting of greater omega-3 PUFA intake or greater MUFA intake
not all studies found a low OR for visual impairment. The studies
conducted by Parekh et al. [36] and Seddon et al. [44] both showed
statistically significant effects for the opposite association compared to
the overall trend. Different factors such as picky eating, dietary
limitations and restrictions, and reduced income can lead to inadequate
consumption of macronutrients and micronutrients due to the elimina-
tion of certain foods from the diet. This has been found to be correlated
with the development of adverse visual outcomes as the nutrients needed
to maintain visual function are insufficient or absent.
These findings are in agreement with many case studies, which report
adverse visual outcomes due to picky eating. Results included a decline in
visual function [46], progressive vision loss, dry eyes, & photophobia
[47], and dry eyes & xerophthalmia [48]. These cases all demonstrate the
potential for the development of severe and sometimes irreversible
growth and neurologic consequences secondary to a highly restrictive and
selective diet. Picky eaters are often deficient in essential micronutrients
as they generally do not consume significant quantities of dairy, fruits,
vegetables, and protein. Micronutrient insufficiencies are a substantial
cause of morbidity and mortality globally [49–51]. Although malnutri-
tion is less common in developed countries such as those included in this
meta-analysis, it can occur in very picky eaters and those with severely
restricted diets. Early recognition is important to prevent potentially
irreversible future health consequences.
The association between a healthy and balanced diet and optimal
health and disease prevention is well documented; however, nutritional

Fig. 6. Forest plot showing a significant increase in the aggregated odds ratio for the development of age-related eye disease with inadequate fish intake.

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K.D. Cirone JFOP 3 (2023) 100036

Fig. 7. Forest plot showing a non-significant increase in the aggregated odds ratio for the development of age-related eye disease with inadequate monounsaturated fatty
acid consumption.

education for healthcare providers and professionals remains insufficient
to provide adequate patient recommendations [52,53]. This indicates a
clear need for an improved understanding of nutrition among healthcare
providers to allow for the provision of adequate nutritional advice to
improve disease management and outcomes. The approach to chronic
disease management within medical practice continues to evolve.
Interventions focusing on lifestyle modifications such as remaining
active, following a balanced diet, maintaining a healthy BMI, and
appropriately managing stress have become a common addition to most
treatment plans [54]. These principles should also be incorporated to
prevent and manage visual conditions.
Limitations of this review include the quantity, type, and quality of the
included studies. Secondly, heterogeneity between studies could be
present due to demographic (study population, baseline characteristics,
inclusion/exclusion criteria), and clinical (visual outcomes and severity,
dietary intervention values, trial period, length of follow-up) differences.
Multiple tests statistics were computed to test heterogeneity, and random-
effects models were used to account for heterogeneity within and between
studies. Finally, although quality was indicated as variable as per the
Downs and Black criteria, all articles were included due to the limited
availability. As execution of RCTs looking at dietary restrictions is
difficult due to ethical regulations, few RCTs were identified during the

Fig. 8. Forest plot showing a non-significant increase in the aggregated odds ratio for the development of age-related eye disease with inadequate polyunsaturated fatty
acid consumption.

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K.D. Cirone
Fig. 9. Forest plot showing a significant increase in the aggregated odds ratio for the development of age-related eye disease with inadequate micronutrient intake.
screen. Further, the RCTs identified during the screen assessed the impact
of supplementation compared to a healthy population instead of reduced
intake and were, therefore, excluded. To generate strong conclusions,
additional high-quality RCTs with long-term follow-up are required.
5. Conclusion
This review suggests that a restricted diet and picky eating may be
associated with visual decline and dysfunction. Avoiding fish and
micronutrients may negatively impact macular health while the results
that assessed an association between unsaturated fatty acids and macular
health were inconclusive. Based on these findings, more good quality
studies are required to make recommendations regarding specific
supplementations and dietary habits; however, picky eaters could be
informed about the need for a varied diet. Diet has been identified as a
modifiable risk factor for visual impairment thus a balanced and
nutritious diet should be encouraged. Modifications to improve diet
quality such as increasing the intake of foods high in nutrients supportive
of retinal health and the avoidance of foods that can induce oxidative
damage may be protective. The high global prevalence of malnutrition
and the increasing rate of observed visual impairment either independent
or secondary to diet indicate the need to implement effective and
validated dietary guidelines. Further education and instruction among
healthcare providers could be initiated to allow for recognition of dietary
insufficiencies and the related adverse outcomes to reduce the potential
development of severe and possibly irreversible consequences.
Disclosure of interest
The authors declare that they have no competing interest.
Human and animal rights
The authors declare that the work described has not involved
experimentation on humans or animals.
Informed consent and patient details
The authors declare that the work described does not involve patients
or volunteers.
8
JFOP 3 (2023) 100036
Author contributions
All authors attest that they meet the current International Committee
of Medical Journal Editors (ICME) criteria for Authorship.
Funding
The authors declare that no funds, grants, or other support were
received during the preparation of this manuscript.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in the
online version, at https://doi.org/10.1016/j.jfop.2023.100036.
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