Longevity implies health retention in the elderly. Living to a ripe old age, but with chronic disease is not really my objective. The first-line of optimal ageing strategies is the prevention of chronic diseases that cause premature disability and/or death. As you would have read in my earlier BLOGS cardiovascular disease forms the greatest pathological burden for society followed by all the cancers, then degeneration of our neurological and musculoskeletal system. Chiefly this epidemic is driven by the BIG 9 RISK factors (dyslipidaemia, sub optimal diet, lack of physical conditioning, smoking, high BMI, elevated BP, absence of any alcohol intake, diabetes mellitus and stress).
Characteristic of modern society is a clustering of these risks with often dyslipidaemia, obesity, hypertension and smoking co-existing giving rise to a particular Cardio Metabolic Syndrome (old name Syndrome X) accounting for the universal poor ageing I see day-to-day.
We know that Metabolic Syndrome is causally linked with the development of cardiovascular disease, female endocrine disorders, polycystic ovary syndrome (PCOS), non -alcoholic fatty liver disease, gestational diabetes, cancer and compromise of immune function. The commonest cause of endocrine disorder in premenopausal women is metabolic syndrome. The commonest cause of liver disease in society is metabolic syndrome (fatty liver), not viral hepatitis, and not alcohol. Metabolic Syndrome increases the risk of death from all causes. The fact that Metabolic Syndrome impairs the immune system and promotes inflammation means that it is linked to all diseases in which inflammation is now known to play a major role, for example cardiovascular disease, cancer and the neurodegenerative disease like Alzheimer’s disease.
Longevity is a legacy of a positive lifestyle, and such a lifestyle results in youthful looks and good functional and physical performance. Several domains of lifestyle medicine exist and attention to each domain is the basis of holistic healthcare. These domains include:
- Physical and Metabolic well-being. People with optimal control of the 9 RISK factors tend to age well with no chronic disease.
- Psychosocial and Spiritual well-being. People in loving caring relationships have objectively better lives, and are more likely to retain their mental, spiritual and physical health.
- Optimum nutrition – the avoidance of substance use including sugar, salt and many of the unhealthy chemicals that are in the food we eat.
- Exercise – the benefits of exercise are, or should be, obvious (see earlier BLOG).
- Sexual health – please do not underestimate the importance of sexual health. Recent studies have demonstrated how beneficial sexual function is for longevity, social, and physical well-being.
- Sleep – our world is under siege by an epidemic of sleeplessness and poor sleep hygiene. Modern medicine has simply failed to realize the importance of sleep.
- Detoxification – over the last few years scientists have begun to understand the importance of environmental toxicity in the progression and advancement of premature ageing and the promotion of chronic disease.
Natural medicine must be combined with advanced preventive medicine strategies in the practice of “anti-ageing” or recuperative medicine. Here lies the aim of this BLOG to discuss the role of nutrition and supplements in the support of “healthy” ageing medicine.
THE IMPORTANCE OF NUTRITION IN OPTIMAL AGEING:
The anti-ageing diet (will be covered in more detail in part 2 of this BLOG) should be appropriate in calories, but nutrient dense. Calorie restriction is of paramount importance to anyone who wants to live a long and healthy life. The diet should contain as little carbohydrate as possible and to balance saturated fat enriched with mono and polyunsaturated fatty acids particularly Omega-3 fats. Eating plenty of fiber – at least 25 grams per day – is important, as is eating a modest amount of mixed protein, preferably vegetable, fish and meat protein. Lastly, the diet should be rich in minerals and natural vitamins and “natural” antioxidants.
Free radicals and antioxidant oxidative tissue damage is a the key process of pathological ageing. The free radical damage theory of ageing is, undeniably, the most tenable theory of ageing. Despite this unfortunately there is no clinically proven trials worldwide that dietary supplements objectively reduce pathological (cardiovascular) ageing.
In fact a review article posted 01/05/2012 titled “Best Evidence Review of Dietary Supplements and Mortality Rates in Older Women” from the Archives of Internal Medicine. 2011;171:1625-1633, suggests some adverse effects of using common vitamin supplements.
The review describes the findings of a study and puts these results in context.
The business of supplements constitutes a multi billion-dollar industry worldwide. Based on the Third National Health and Nutrition Examination Survey, 40% of men and 50% of women older than 60 years of age consume at least 1 vitamin or mineral supplement. A national survey by the US Food and Drug Administration found that 73% of US adults were found to use dietary supplements in 2002, providing annual sale costs in 2005 of over $20 billion.
The widespread use of dietary supplements is not supported by practice guidelines. The US Preventive Services Task Force (USPSTF) states that there is insufficient evidence to recommend for or against the use of vitamins A, C, E, or multi vitamins with folic acid or antioxidants. Specifically, the USPSTF cites concerns regarding the balance of benefits vs harms of these supplements. The American Medical Association ONLY recommends supplements specifically for seniors who have generalized decreased food intake, while the American Dietetic Association advises low-dose multivitamin and mineral supplements depending on individualized dietary assessment. The American Heart Association emphasises healthy eating patterns rather than supplementation with specific nutrients.
These recommendations against the routine use of supplements are grounded in good evidence. A Cochrane intervention review of 77 randomised controlled trials with 232,550 participants found no evidence to recommend antioxidant supplementation for primary or secondary prevention of mortality. Moreover, there is the possibility of harm related to the use of some supplements. For example, the Alpha-Tocopherol. (Vitamin E) Beta-Carotene Cancer Prevention Trial demonstrated that Beta-Carotene supplements increased the risk for lung cancer among male smokers.
Another recent study discussion raises even more concerns regarding the safety of dietary supplements. The study enrolled 41,836 women between the ages of 55 and 69 years in 1986. Women completed validated food frequency questionnaires at baseline and in 2004, and the use of any of 15 different dietary supplements was queried in 1986, 1997, and 2004.
The main study outcome was the relationship between supplement use and all-cause mortality, which was assessed from state and national registries. Researchers adjusted this result to account for the following factors: age, energy intake, educational level, place of residence, smoking status, body mass index (BMI), waist-to-hip ratio, physical activity, diet composition, alcohol consumption, the use of oestrogen therapy, and the presence of diabetes mellitus and hypertension.
A total of 38,772 women provided study data. The mean age of participants at enrollment was 61.6 years, and over 99% of women were white. The average BMI was 27 kg/m2 at baseline and follow-up in 2004, and the majority of women were physically active. The average consumption of fruits and vegetables exceeded 6 servings per day during the study period. Out of this population, 36.8% of women reported hypertension, and 6.8% had diabetes.
The use of dietary supplements increased with time; 62.7% of women reported use of at least 1 supplement in 1986, and this figure rose to 85.1% by 2004. The most commonly used supplements were calcium, multi vitamins, vitamin C, and vitamin E.
Women who used supplements generally had better health characteristics compared with non users. They had higher educational status, lower BMI and waist-to-hip ratio, and lower rates of diabetes and hypertension compared with non users, and they were also less likely to smoke and had a healthier dietary profile. Supplement users were also more likely to use oestrogen therapy compared with non users.
There were 15,594 deaths (40.2% of the study cohort) during a mean follow-up period of 19 years. In fully adjusted models, the use of multiple supplements was associated with a higher risk for mortality, including multi vitamins (hazard ratio [HR], 1.06; 95% confidence interval [CI], 1.02-1.10), vitamin B6 (1.10; 1.01-1.21), folic acid (1.15; 1.00-1.32), iron (1.10; 1.03-1.17), magnesium (1.08; 1.01-1.15), zinc (1.08; 1.01-1.15), and copper (1.45; 1.20-1.75). The use of vitamin A, Beta-Carotene, and selenium were associated with non significant trends toward a higher risk for mortality, and the use of vitamins C, D, and E had nearly no effect on mortality. In contrast, taking calcium supplements significantly reduced the risk for mortality (HR, 0.91, 95% CI, 0.88-0.94).
The findings of the current study should be sobering for the most ardent supporters of supplements, and patients need to understand the potential risks inherent in the treatment choices they make.
There are many clinical reports of the neutral or “placebo” effect of taking expensive mineral and vitamin supplements. Another recent clinical trial of Selenium and Vitamin E Cancer Prevention Trial (SELECT) found that neither selenium nor vitamin E supplements reduced the risk for prostate cancer. However, an updated analysis, which appeared in the October 12 2011 issue of Journal of the American Medical Association (JAMA), indicated that vitamin E supplementation can significantly increase the risk for prostate cancer.
This observed increase in risk demonstrates “the potential for seemingly innocuous yet biologically active substances such as vitamins to cause harm”.
There is no reason for otherwise healthy men to take vitamin E as Vitamin E doesn’t prevent prostate cancer; it doesn’t prevent any cancer, despite the claims of some, and it doesn’t promote cardiovascular health, despite the claims of many.
There is no evidence to support any of these claims, yet thousands or even millions of men include vitamin E in their supplementation. What this tells us is that even though we assume something to be good, it may not be. In fact, it may be harmful. The assumption is that because vitamin E is an antioxidant, it’s good for us. But that isn’t the case.
The “take-home” message from world clinical trials therefore suggest:
- Nearly half of older adults routinely use dietary supplements, with higher rates of use among women compared with men.
- The routine use of many dietary supplements is discouraged in pretty much ALL allopathic practice guidelines worldwide.
- The use of multi vitamins, vitamin B6, folic acid, iron, magnesium, zinc, and copper was associated with a higher risk for mortality among older women.
- Conversely, calcium supplements were associated with a lower risk for mortality.
Perhaps the only supplement to show evidence base in preserving ageing are the phytochemicals, polyphenols and omega 3 fats.
Extensive evidence from three decades of research that fish oils, or more specifically the omega-3 polyunsaturated fatty acids (PUFAs) contained in them, are beneficial for everyone. This includes healthy people as well as those with heart disease-including post-myocardial infarction (MI) patients and those with heart failure (HF), atherosclerosis, or atrial fibrillation. The American Heart Association (AHA) actively promotes that those with known cardiovascular disease eat four or five oily-fish meals per week or take the equivalent in omega-3 supplements; healthy people should consume around two fatty-fish meals per week or the same in supplements.
Most of the data on omega-3 have been obtained in trials using docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), the long-chain fatty acids in this family. The most compelling evidence for optimal ageing and cardiovascular benefits comes from four controlled trials of almost 40 000 participants randomised to receive EPA with or without DHA in studies of primary and secondary prevention, after heart attacks, and most recently in patients with heart failure.
Three large randomised trials-the Diet and Reinfarction Trial (DART), the Gruppo Italiano per lo Studio della Sopravvivenza nell’ Infarto Miocardico (GISSI)-Prevenzione, and the Japan EPA Lipid Intervention Study (JELIS)-have indicated that omega-3 PUFAs lower CV risk in both the primary- and secondary-prevention settings. The benefit is different in different studies but can be as much as 30%. The effects are seen on total mortality, sudden death, coronary heart disease mortality, and total cardiovascular mortality.
There is also evidence of benefit in atherosclerosis and in a wide range of arrhythmias, with the most significant effect and potential benefit seen in “the current epidemic” of atrial fibrillation. The benefits of omega 3 PUFA appears to be on autonomic tone and anti-inflammatory effects.
Recently, the potential benefits of omega-3 PUFA have been extended to the prevention and treatment of heart failure (HF). Although the reduction in events was only 8% to 9% in the recent GISSI-HF trial, which is not huge, when you think of HF, it’s a very serious disorder, and in GISSI-HF, those patients were treated vigorously for their HF, so they were on good therapy, and adding just one [omega-3 PUFA] pill a day reduced deaths by between 8% and 9%, which is a pretty nice additional benefit.
They data on omega-3 PUFAs in dyslipidaemia is important, noting that the FDA has approved one such supplement for the treatment of very high triglyceride levels.
Recommendations from the AHA, European Society of Cardiology, and WHO, I certainly take and recommend that people consume at least 500-800 mg per day of EPA/DHA-equal to around two fatty-fish meals per week-or supplementing Omega 3 capsules 2-4 g daily on the days they were not eating such fish.
Some really exciting research at the University of California, San Francisco reveal in the January 20, 2010 issue of the Journal of the American Medical Association (JAMA) that heart disease patients who have higher levels of omega-3 fatty acids experience a lower rate of reduction in telomere length over time. Telomeres, which are protective DNA sequences at the ends of chromosomes, shorten with the age of the cell, and their length is a marker of biological ageing.
Increased oxidative stress has been identified as a factor in telomere shortening and ageing, the ability of omega-3 fatty acids to help reduce oxidative stress as previously determined by lower levels of F2-isoprostanes and higher levels of the body’s antioxidant enzymes in response to supplementation could explain the benefit observed in the current research. Additionally, the researchers speculate that omega-3 fatty acids could enhance the activity of telomerase (the enzyme that helps maintain telomere length) in healthy tissue, while suppressing it in cancer cells.
In this longitudinal study baseline levels of marine omega-3 fatty acids were associated with decelerated telomere attrition over 5 years. “These findings raise the possibility that omega-3 fatty acids may protect against cellular ageing in patients with coronary heart disease.”
Despite the general failure of Vitamin and some mineral supplements it is important to know that naturally occurring antioxidants and chemicals have tissue or organ-specific effects, for example:
- Ellagic acid, which is found predominantly in raspberries and pomegranates, protects against breast cancer.
- Curcumin, the antioxidant present in the Indian spice turmeric, supports cognition and may even help to prevent Alzheimer’s disease. Recent research suggests that curcuminoids may also be potent analgesics.
- Lycopene, which is found in tomatoes, supports the prostate and may protect against prostate cancer. Some reserch suggests that Lycopene may also benefit the retina.
- Alpha-lipoic acid is of geat benefit to people with diabetes or the metabolic syndrome, as it is an insulin sensitizer. It also plays a major role in the prevention of the neuropathic complications of diabetes.
- Polyphenols, which are found in abundance in green tea and coffee and red wine should not be underestimated. There is a large body of evidence that suggests that catechins, particularly epigallocatechin gallate (EGCG), are very powerful and very versatile biological agents.
ADVANCED GLYCATION END PRODUCTS (AGEs)
Another important factor to consider when thinking about ageing is tissue glycation. The undesirable cross-linking of sugar or aldehydes with protein results in the formation of advanced glycation end products (AGEs), which cause proteins to lose their functional integrity. Certain diseases, for example Metabolic Syndrome and Diabetes Mellitus in which oxidative stress caused by hyperglycemia (elevated blood Glucose), lead to the formation of high levels of AGEs. Ideally correct nutrition and lifestyle can correct fluctuation of high Glucose levels and the high Insulin associated (Insulin resistance).
My next BLOG will cover this in detail.