Confidential

Healthy Aging The Key to Wellness and Better

Performance

Raul J Seballos, MD, FACP

Vice-Chair, Preventive Medicine Wellness Institute Cleveland Clinic

© Cleveland Clinic 2015 DOS Course 2015 1

Who is this man?

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Eubie Blake

• Born as “James Hubert Blake”

• Both parents were former slaves

• He had seven siblings – All had died as infants – He was the only child that lived

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Eubie Blake

• Composer and pianist of ragtime, jazz, and popular music, as well as a lyricist

• Continued to play and record until shortly before what everyone thought was his 100th birthday. He uttered the memorable quote…

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Eubie Blake

“If I’d known I was going to live this long,

I’d have taken better care of myself.”

Eubie Blake

Feb. 7, 1887–Feb. 12, 1983; age 96

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• Review current life expectancy stats

• Discuss causes of premature mortality

• Review of studies showing contributing factors to

longevity and healthy ageing

• Discuss the role of supplements on aging and prevention

of cardiovascular disease and cancer

Objectives

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• Now at 78.8 years

• At age 65 • Men will live about 18 years of life left • Women will have about 20.5 years left • Gap increased slightly since 2011

• Hispanic death rates remain lower than whites and blacks

• Heart disease and cancer remain the top leading cause of death in the US

Life Expectancy (CDC, 10/2014)

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Life Expectancy at Birth

SOURCE: CDC/NCHS, Health, United States, 2013, Figure 1. Data from the National Vital Statistics System.

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Death Rates For All Ages

SOURCE: CDC/NCHS, Health, United States, 2013, Figure 1. Data from the National Vital Statistics System.

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Death Rates For Heart Disease and Cancer By Sex in US (1980-2011)

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Estimated New Cancer Cases* in the US in 2013

51% 52%

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Estimated Cancer Deaths in the US in 2013

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Causes of Premature Mortality

Behavior40%

Medical access10%

Genetics30%

Environment5%

Social15%

Obesity

Sedentary lifestyle

Smoking

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Sardinians (Italy) Drink red wine (in

moderation) Share work burden with

spouse Eat pecorino cheese

(Omega 3)

Okinawans (Japan) Keep lifelong friends

Eat small portions Find purpose

Adventist (California) Eat nuts and beans

Observe the Sabbath Have faith

ALL • Don’t smoke • Put family first • Be active every day • Keep socially engaged • Eat fruits, vegetables,

and whole grains Super seniors in three widely separated regions share a

number of key habits, despite many differences in

backgrounds and beliefs.

Adapted from National Geographic, November 2005

How They Live Longer

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• In 1970, half of all people in developed countries were under 28;

• By 2020, half will be over 50!

• Explosion of Americans over age 65 in next 20 years • By 2030, 72 million people

• 85+ group fastest-growing segment of the U.S. population

• Currently 55,000 centenarians – 1 of every 10,000 persons presently alive!

The aging population

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• Weight control

• Diet

• Exercise

• Stress management

• Improved health benefits

• Lower mortality rate

• Supplements

Turning Back The Clock: Adopting A Healthy Lifestyle

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• Weight control

• Diet

• Exercise

• Stress management

• Improved health benefits

• Lower mortality rate

• Supplements

Turning Back The Clock: Adopting A Healthy Lifestyle

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• Body Mass Index (BMI): – Weight/height2 = kg/m2 – lbs/inches2 x 704.5

• What’s “normal?” – Underweight: less than 20 kg/m2 – Normal: 20 - 24.9 kg/m2 – Overweight: 25 - 29.9 kg/m2 – Obese: greater than 30 kg/m2

• Waist circumference – More than 40” or 101 cm (men) and 35” or 89 cm (women) – Now considered a risk factor for diabetes and heart disease

Maintain Appropriate Weight

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BMI=25 BMI=30

• 5’6” (1.68 m) 155 (70.5 kg) 185 lbs (84.1 kg)

• 5’8” (1.73 m) 165 lbs (75.0 kg) 195 lbs (88.6 kg)

• 5’10” (1.78 m) 175 lbs (79.5 kg) 210 lbs (95.5 kg)

• 6’0” (1.83 m) 185 lbs(84.1 kg) 220 lbs (100.0 kg)

Maintain appropriate weight

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The Causes of Overweight

Fuel intake Fuel burned

1 lb fat = 3,500 calories

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Obesity - Related Health Concerns

• Cancer in men – Esophagus – Thyroid – Colon – Kidney

• Cancer in women

– Endometrial – Gallbladder – Esophagus – Kidney

• Diabetes

• Hypertension

• Osteoarthritis

• Stroke

• High cholesterol

• Sleep apnea

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• In 2003-2004 – 17.1% of children and adolescents were overweight – In adults, age > 20

Obesity

Men Women

Overweight or obese 70.8% 61.8%

Obese 31.1% 33.2%

Ogden CL et al. Prevalence of Overweight and Obesity in the United States, 1999-2004. JAMA. 2006;295:1549-1555.

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2000

Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010

(*BMI ≥30, or about 30 lbs. overweight for 5’4” person)

2010

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

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• Weight control

• Diet

• Exercise

• Stress management

• Improved health benefits

• Lower mortality rate

• Supplements

Turning Back The Clock: Adopting A Healthy Lifestyle

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• Low salt 2.4 gm/day

• Fish Salmon, mackerel, herring, trout

3 times/week

• Fish Oil capsules 1,000 mg 3 times/day

EPA + DHA = 1000 mg/day

• Fiber 35 gm/day

• Olive or Canola oil Primary fat source

• Whole grain products (less processed) – 3 servings/day – Lowers risk of heart disease, diabetes and some cancers

Mediterranean Diet

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• Nuts ½ cup/day (walnuts, pecans, almonds, etc).

• Flavinoids - dark skinned fruit (blueberries, blackberries, purple grapes)

• Red wine or purple grape juice 2-4 oz per day; Grape seed extract

• Fresh fruit and vegetables, legumes at 4-5 serving per day

• Green tea 2 cups/day

• Lean meats - chicken (without skin)

• Red meat - once or twice/month

Mediterranean Diet

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• Avoid partially hydrogentated anything

• Avoid high fructose syrups

• Eggs 0 - 4 x per week

• Recommend fruits with high antioxidants – Cranberries, corn, apple, red grapes and strawberries include

peels

• Low antioxidants have no peel – Pineapple, grapefruit, orange, bananas

Mediterranean Diet

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• Weight control

• Diet

• Exercise

• Stress management

• Improved health benefits

• Lower mortality rate

• Supplements

Turning Back The Clock: Adopting A Healthy Lifestyle

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Exercise

Byberg, L. et al. BMJ 2009

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Exercise

Byberg, L. et al. BMJ 2009

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Cardiorespiratory (Aerobic) Exercise - Light

Light Intensity Activities < 3 METs Sleeping 0.9 Watching television 1.0 Writing, desk work, typing 1.8 Walking, 1.7 mph (2.7 km/h), level ground, strolling, very slow 2.3 Walking, 2.5 mph (4 km/h) 2.8

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Cardiorespiratory (Aerobic) Exercise - Moderate

Moderate Intensity Activities 3 to 6 METs Bicycling, stationary, 50 watts, very light effort 3.0 Walking 3.0 mph (4.8 km/h) 3.3 Calisthenics, home exercise, light or moderate effort, general 3.5 Walking 3.4 mph (5.5 km/h) 3.6 Bicycling, <10 mph (16 km/h), leisure, to work or for pleasure 4.0 Bicycling, stationary, 100 watts, light effort 5.5

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Cardiorespiratory (Aerobic) Exercise - Heavy

Vigorous Intensity Activities > 6.0 METs

Jogging (1 mile in 13-14 min) 6.0

Singles tennis, squash, racquetball 7-12

Calisthenics (Push-ups, sit-ups, pull-ups, jumping jacks), heavy, vigorous effort

8.0

Jogging (1 mile in 12 min; 5 mph) 8.0

Rope jumping rope, jogging (1 mile in 10 min; 6 mph) 10.0

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• Weight control

• Diet

• Exercise

• Stress management

• Improved health benefits

• Lower mortality rate

• Supplements

Turning Back The Clock: Adopting A Healthy Lifestyle

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Stress and Performance

Pressure

Performance

Optimum Pressure

High anxiety & stress

Boredom

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• Uncontrolled stress may be a cause for a number of acute physical symptoms

• Stress may increase risk for chronic illnesses – High blood pressure – Cardiovascular disease (heart disease, stroke) – Metabolic syndrome – Headaches – Irritable bowel syndrome – Chronic pain – Anxiety and depression – Cancer?

Stress

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• Sleep

• Nutrition

• Exercise

• Time management

• Social support

• Specific stress reduction techniques – Breathing, meditation, biofeedback

• Maintaining Work-Life Balance

Stress Management

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• Group of 73,424 Japanese men and women

–Women reporting high stress had two times higher risk of death from stroke and heart disease compared with those reporting low stress

–Relationship weaker for men, but suggested increased risk for heart attacks with higher stress

Stress and Cardiovascular Disease

Iso etal.Ciculation 2002; 106: 1229-1236

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• Figure out what really matters to you in life

• Drop unnecessary activities

• Protect your private time

• Accept help to balance your life

• Plan fun and relaxation

Work Life Balance

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• Weight control

• Diet

• Exercise

• Stress management

• Improved health benefits

• Lower mortality rate

• Supplements

Turning Back The Clock: Adopting A Healthy Lifestyle

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• Healthy habits contributing to longevity

– Mediterranean diet – Alcohol (< 1 drink/day) – Exercise – Non-smoking

• Following all four factors was associated with a 65%

lower risk of death from all causes and cardiovascular

disease.

Healthy Ageing: A Longitudinal Study in Europe (HALE Study)

Knoops KT et al. JAMA. 2004;292:1433-1439

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• Health Professional Follow-Up Study (2006) – 43,000 US male physicians with f/u 16 yrs – No smoking – BMI < 25 – Exercise 30 min/d – Low animal fat diet – Alcohol 1-2 drinks/day – 62% lower risk of heart attacks

Healthy Ageing: Proven Benefits

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• Women’s Healthy Study (2006) – 38,000 females, age 45 and older, 10 yr f/u – No smoking – BMI < 22 – Exercise 4 d/wk – Low fat and high fiber diet – Alcohol 4-10 drinks/week – 55% lower risk of stroke

Healthy Ageing: Proven benefits

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• Absence of – Smoking – Diabetes – Hypertension – Obesity – Sedentary

• Contributed to longer lifespan in men

• Delayed occurrence of cancer and heart disease (i.e. gained relatively disease and disability-free years)

Factors to Exceptional Longevity

Yates, L. B. et al. Arch Intern Med 2008;168:284-290

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• Four intervention for adopting a healthy lifestyle: – 5 or more fruits and vegetables daily – Regular exercise (at least walking 2.5 hrs/week) – Weight at BMI 18.5-30 – No smoking

• Study population – 15,792 men and women – Age 45-64 – Follow up visits up to six years

Does Adopting A Healthy Lifestyle Really Turn Back The Clock?

King DE et al. Am J Med 2007;120:598-603.

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• Only 8.5% practiced healthy lifestyles • Only 8.4% newly adopted lifestyle behaviors • Those who adopted all four healthy lifestyle behaviors

– Death from all causes lowered by 40% – Cardiovascular disease events lowered by 35%

• Less likely to adopt a healthy lifestyle > age 45 – Men – African American – Lower income – History of high blood pressure or diabetes

Does Adopting A Healthy Lifestyle Really Turn Back The Clock?

King DE et al. Am J Med 2007;120:598-603.

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Probability of An Additional 20-year Survival To Age 90 Years For A 70-year-old Man

Probability of living to age 90 is 54% in absence of: smoking, diabetes, obesity, hypertension, and sedentary lifestyle vs. 4% with all five factors present.

Yates, L. B. et al. Arch Intern Med 2008;168:284-290.

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• Weight control

• Diet

• Exercise

• Stress management

• Improved health benefits

• Lower mortality rate

• Supplements

Turning Back The Clock: Adopting A Healthy Lifestyle

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• Multivitamin

– Sesso et al (JAMA 2012;308:1871) – Physician Health Study II –14,641 male physicians, > 50 yo, 1997-2011, DBPCT –No difference in major CV events, MI, stroke, and CVD

– Gaziano et al (JAMA 2012;308:1871) – Physician Health Study II

–Total cancers (except nonmelanoma skin cancer) –Multivitamin group had lower incidence of cancer vs Placebo (17.0 vs

18.3 events per 1000 person-yrs, P=0.04, HR 0.92 or 8% reduction) –However, no difference in incidence and death from the 3 most

common cancers in men (prostate, colorectal, and lung) –No harmful effects (eg. Increased risk of prostate cancer)

Supplements for Prevention

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• Multivitamin

– Grodstein al (Ann Int Med 2013;159:806) – Part of Physician Health Study II –5,947 male physicians, mean age on enrollment was 72 yo, DBPCT –No difference in alcohol use, smoking, DM, TN, hyperlipidemia,

exercise activity or depression –East Boston Memory test, Telephone Interview for Cognitive Status,

and other validated test for global composite and verbal memory scores. Testing x 4 over 8.5 years

–No significant difference over time between two groups in cognitive function change

Supplements for Prevention (Cognition)

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• Multivitamin and Mineral

– Mursu et al (Arch Int Med 2011;171:1625) – Iowa Women’s Health Study –38,772 women, age 55-69, 1986-2008 –Use of multivitamins, Vit B6, folic acid, iron, magnesium, zinc, and

copper were associated with increased risk of total mortality –Calcium was associated with a 3.8% reduction in mortality.

Supplements for Prevention

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• Multivitamin and antioxidants

– Myung et al (BMJ 2013;346:f10) –Meta-analysis of 50 trial for CV disease prevention –Outcomes: CV events, CV death, MI, angina, sudden cardiac death,

stroke and TIA –Vitamins and antioxidants did NOT reduce risk for major CV events

Supplements for Prevention

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• Antioxidants

– Are they associated with higher or lower all-cause mortality – Bjelakovic et al (JAMA 2013;310:1778)

–Not associated with lower all cause mortality –Beta carotene, Vitamin E and higher doses of Vitamin A may be

associated with a higher all-cause mortality –Review does not support the use of antioxidant supplements as a

primary or secondary preventive measure

Supplements for Prevention

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Supplements for Prevention

Bjelakovic et al (JAMA 2013;310:1778)

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• USPSTF (2/2014) – Grade D:

–Recommends against the use of β-carotene or vitamin E supplements for the prevention of cardiovascular disease or cancer.

– Grade I: – Insufficient evidence to assess the balance of benefits and harms of

the use of multivitamins for the prevention of cardiovascular disease or cancer.

– Grade I: – Insufficient evidence to assess the balance of benefits and harms of

the use of single- or paired-nutrient supplements (except β-carotene and vitamin E) for the prevention of cardiovascular disease or cancer.

Supplements for Prevention of CVD and Cancer

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• USPSTF (2/2014)

– Applies only to healthy adults

– Similar conclusion of insufficient evidence to support multivitamins to prevent chronic disease –NIH, Academy of Nutrition and Dietetics, ACS, and American Institute

for Cancer Research

Supplements for Prevention of CVD and Cancer

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• Dehydroepiandrosterone (DHEA) and its main metabolite Sulfated DHEA (DHEA-S)

– Weak androgen

–Critical precursor in sex hormone metabolism

– Peak levels in early adulthood –Then decrease 10% per decade until age 70

Supplements for Prevention

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• Testosterone and DHEA-S

Supplements for Prevention

NEJM 2006;355:16

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• Dehydroepiandrosterone (DHEA) and its main metabolite Sulfated DHEA (DHEA-S) – Nair et al (NEJM 2006;355:1647) – 2 yr RDBPCT of 87 men and 57 women with low DHEAS – 29 M (DHEA 75 mg), 27 M (Testo), 31 M (placebo) – 27 W (DHEA 50 mg), 30 W (placebo)

– Outcome –Physical performance, Body comp, BMD, Glucose tolerance, and QOL

– No effect on body composition, VO2 max, muscle strength, or

insulin sensitivity, and QOL. –No adverse events with treatment

– Increase in BMD

Supplements for Prevention

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• Dehydroepiandrosterone (DHEA) and its main metabolite Sulfated DHEA (DHEA-S)

– Potential Benefits

–Helped relieve mild to moderate depression –May help when used in combination with regular treatment for

the following conditions –Obesity –Systemic lupus (SLE) –Adrenal insufficiency

Supplements for Prevention

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• Dehydroepiandrosterone (DHEA) and its main metabolite Sulfated DHEA (DHEA-S) – National Standard and the NIH - evidence is unclear whether

DHEA has any significant benefit in treating conditions such as: – Alzheimer’s disease – Low bone density – Heart disease – Cervical cancer – Chronic fatigue syndrome – Crohn's disease – Infertility – Psoriasis – Rheumatoid arthritis – Schizophrenia – Sexual dysfunction

Supplements for Prevention

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• Dehydroepiandrosterone (DHEA) and its main metabolite Sulfated DHEA (DHEA-S)

– National Standard and the NIH – No or little evidence to support

use of DHEA in treating conditions such as: –Fibromyalgia, –Addressing issues with memory or muscle strength, or –Enhancing and stimulating the immune system

Supplements for Prevention

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