The Okinawa Research Center for Longevity Science

The Okinawa Research Center for Longevity Science (ORCLS) is a leading nonprofit biomedical research institute built on the foundation of the Okinawa Centenarian Study (OCS), the longest, continuously running study of hundredyear-olds in the world (established 1975). The ORCLS was officially established in 1997 by Dr. Makoto Suzuki, the Principal Investigator of the Okinawa Centenarian Study (OCS), to continue research on Okinawan centenarians after Dr. Suzuki's retirement from University of the Ryukyus, Faculty of Medicine, where the OCS was conducted until 1997. Since then the ORCLS has been working together with University of the Ryukyus, Faculty of Medicine (Okinawa), Okinawa International University, Department of Human Welfare (Okinawa), Pacific Health Research Institute (Hawaii), John A. Burns School of Medicine, University of Hawaii at Manoa (Hawaii), and Tokyo Metropolitan Institute of Gerontology (Tokyo). Supports have been provided by Japan Ministry of Health, Labour and Welfare; Japan Society for the Promotion of Science; Japan Ministry of Education, Culture, Sports, Science and Technology; Prefectural Government of Okinawa, and most recently, by the US National Institute on Aging/National Institutes of Health. The main study carried out by ORCLS, the Okinawa Centenarian Study, is a populationbased study of hundred-year-olds (centenarians) and other elderly in Okinawa, Japan. The study began in 1976, after the Japan Ministry of Health, Labour and Welfare confirmed initial reports of outstanding health and long life in Okinawa through validation of birth certificates and other statistical data. Today, Okinawa is known as the region with one of the world`s longest life expectancies, as well as the largest number of centenarians per 100,000 population; and OCS has investigated over 900 centenarians. Studies have concentrated on the genetics, diets, functional abilities, cognitive abilities and psychology of the centenarians. Mission and Goals The mission of the Okinawa Research Center for Longevity Science is to carry out cutting edge research on factors associated with healthy aging and to provide scientific, evidence-based information on health and longevity to the public, as

well as to researchers and research institutes around the world for the betterment of the health and lives of all people. To accomplish this mission, ORCLS has set these goals:

Uncover the genetic and environmental (diet, lifestyle, psychological, social) factors responsible for the healthy aging phenomenon in Okinawan elderly Continue to establish scientific databanks on genetics, diets, functional abilities, cognitive health, and other factors for further research on healthy aging Continue to establish biological repositories useful for research on healthy aging Collaborate with other researchers and research institutes to widen understanding and share knowledge Engage in cutting edge translational work to translate the study results into clinically useful interventions for improving the health of older persons Educate geriatric/gerontology students and researchers in the principals of healthy aging Promote healthy aging to governments, government agencies, nongovernmental organizations and responsible corporations

The Team

Makoto Suzuki MD PhD is a cardiologist and geriatrician. He is Professor Emeritus and former Director of the Department of Community Medicine at the University of the Ryukyus in

Okinawa, Japan. Currently, he is Director, Okinawa Research Center for Longevity Science, in Urasoe, Okinawa. He recently retired from his position as professor in the Department of Human Welfare at Okinawa International University. He is Principal Investigator of the Okinawa Centenarian Study, a Japan Ministry of Health-funded study of the world's healthiest and longest-lived people. The study is entering its 36th year and is the longest continuously running centenarian study in the world. Dr. Suzuki has over 200 peer-reviewed scientific publications and his total publications number over 700 including scientific manuscripts, conference proceedings, books and book chapters on aging and health. As the first scientist to make a comprehensive study of Okinawan longevity, he organized a conference in 1995 in which the Director of the World Health Organization supported the declaration of Okinawa as a World Longevity Region. He was recently presented with the Nishi-Nihon News Award to recognize his lifetime contributions to health and well being in Japan.

Bradley Willcox MD, MS is a Physician-Investigator in Geriatrics. He currently holds the post of Medical Director, Department of Research and Planning, The Queen's Medical Center, Honolulu, Hawaii as well Associate Clinical Professor, Department of Geriatric Medicine, John A. Burns School of Medicine, University of Hawaii. Dr. Willcox is also an Investigator at the Pacific Health Research and Education Institute (PHREI) in Honolulu and Investigator, Geriatrics and Gerontology at Kuakini Medical Center. Additionally, Dr. Willcox works as Staff Physician, Orthopedic and Long Term Care Hospitalist Programs, The Queen's Medical Center and Medical Team Care Attending Physician, John A. Burns School of Medicine, University of Hawaii. Dr. Willcox is Co-Principal Investigator of the Okinawa Centenarian Study and Principal Investigator of the U.S. NIH-NIA funded "Hawaii Lifespan Study". He received his Bachelor and Master of Science from the University of Calgary and his MD from the University of Toronto and subsequently trained in internal medicine at the Mayo Clinic and

geriatrics at Harvard Medical School. He has published and lectured extensively in aging, nutrition and health, especially with reference to Okinawan longevity and has won numerous awards for his work. Dr. Willcox is currently funded by several research grants from the US National Institutes of Health including the Hawaii Lifespan Study (NIA) and the Prostate, Lung, Colon, Ovarian Cancer Trial (NCI) to study geneenvironment interactions that lead to healthy aging and screening to lower cancer risk.

Dr. Craig Willcox, Ph.D. is an internationally recognized expert in healthy aging and cross-cultural gerontology with training in medical anthropology, gerontology and public health sciences. A native of Calgary, Canada, he is currently Professor of International Public Health & Welfare and Gerontology, at Okinawa International University, and a Co-Principal Investigator of the Okinawa Centenarian Study, a U.S. National Institutes of Health and Japan Society for Promotion of Science funded study of the genetic and lifestyle determinants of exceptional longevity. Dr. Willcox is also Research Associate at University of Hawaii, Faculty of Medicine, Pacific Health Research Institute, where is a co-investigator on several NIH projects exploring the genetic epidemiology of healthy aging. He is also researcher in residence at Okinawa Research Center for Longevity Science. After completing undergraduate work at the University of Calgary, Dr. Willcox trained in medical anthropology, gerontology and public health sciences at the University of the Ryukyus, where he earned his Master's of Health Sciences degree and at the University of Toronto where he earned his doctorate. He has published and lectured extensively over the past decade in the areas of human ecology and aging, as well as nutritional and public health approaches to successful aging. Besides the epidemiology of healthy aging, Dr. Willcox's current research interests

include exploring the interconnections between aging and the disability process among the oldest old in both Okinawa and Hawaii. Dr. Willcox is a member of several professional societies including the International Epidemiological Association and Gerontological Society of America, among others. His research work has been supported by the U.S. National Institutes of Health, U.S. National Institute on Aging, Medical Research Council of Canada, University of Toronto, The Japan Society for Promotion of Science, and the Japan Foundation, among other sources. Dr. Willcox is also an adjunct associate editor for several top gerontology journals including the Journal of Gerontology: Medical and Biological Sciences and has co-authored two best-selling books on public health approaches to healthy aging, The Okinawa Program and The Okinawa Diet Plan. The Okinawa Program was a New York Times bestseller and nominated as Best Wellness Book of the Year (Books for a Better Life Awards) as well recognized as one of the Top 50 Books of the Year by both Barnes and Nobles and Amazon.com in 2001. More information on Dr. Willcox's research and academic publications can be found at:okicent.org and orcls.org

Evidence-Based Gerontology One of the most important things about the Okinawa Centenarian Study is the fact that it is based on solid evidence. The most important evidence needed for any centenarian study is reliable age-verification data. Throughout Japan (including Okinawa prefecture), every city, town, and village records birth, marriage and death data (among other data) in a koseki (family register). This system was instituted throughout Japan in the 1870's. The koseki is supplemented by a regular census undertaken every five years. Life tables calculated from this database show one of the world's longest life expectancies and prevalence data show the world's highest known concentration of centenarians for any country or state. FOCUS AREAS AND FINDINGS After examining over 900 Okinawan centenarians and numerous other elderly in their seventies, eighties, and nineties, some fascinating findings have emerged. One, genetic factors appear important to human longevity, including Okinawan longevity. Two, it has also become clear that the Okinawan lifestyle provides many reasons why older Okinawans are so remarkably healthy so far into their senior years. Discovering the reasons for the apparent genetic and environmental advantages could have an important impact on our health and well-being in the West. Below appear some of the key findings and what they mean in terms of healthy aging -- for the Okinawans, and the rest of us.

1. Genetics, Healthy Aging and Longevity Identifying factors that help us remain healthy, vigorous and disability-free at older ages is one of our major research priorities. Since the completion of the Human Genome Project and the HapMap Project (a project to identify common variations in human genes), a promising novel strategy by some human longevity researchers is to try to identify genes (and variations of those genes) that impact human aging and longevity. If such genes and their genetic pathways can be identified then novel therapies might be created that affect the biology of these pathways. This may help prevent or treat ageassociated diseases and perhaps even slow aging itself. Such therapies might include interventions as simple as diet and focused exercise, specific food compounds, neutraceuticals or pharmaceuticals. How much of human longevity is due to genes? Estimates of the heritability of human lifespan vary from 10-50% with the most common finding being that about a third of human lifespan may be heritable. Phenotypes that suggest slower aging, such as survival to 90+ years, may have an even stronger genetic basis, which explains why centenarians and near-centenarians tend to cluster in families. But until the discovery of the apolipoprotein E (ApoE) gene, there was little evidence for a single gene effect large enough to impact human longevity. This discovery has been replicated in many populations, suggests that associations with some genes are large. Studies of long-lived humans, such as American centenarians, have helped identify other promising genetic loci for longevity and healthy aging. However, these studies are often limited in scope due to small sample sizes, genetic admixture, and inappropriate selection of controls. Some success has been achieved through use of genetically homogeneous populations with smaller gene pools. Our research group was the first to identify so called "human longevity genes" using centenarians as a study model when we published a study showing that Okinawan centenarians have HLA (human leukocyte antigen) genetic polymorphisms that place them at lower risk for inflammatory and autoimmune diseases (see figure below: Takata et al., Lancet 1987).

We also studied the mortality patterns of centenarian siblings. Past family studies in other populations have shown that there are familial (genetic) components to longevity.

That is, longevity tends to run in families. In support of this, we found that a mortality advantage exists for centenarian siblings versus their age-matched birth cohorts. This advantage appears sustained over the course of the siblings' lives. At each 5-year age interval until age 90 years, siblings of Okinawan centenarians maintained approximately a 50% lower mortality risk. This resulted in an average of 11.8 years extra lifespan compared to their age-matched birth cohort. The sustained mortality advantage over the life course provides further evidence that human longevity has an important genetic component since most environmental mortality advantages, such as education, diminish or disappear completely in older age groups (see figure below from Willcox BJ et al. Siblings of Okinawan centenarians exhibit lifelong mortality advantages. J Gerontol A Biol Sci Med Sci. 2006;61:345-54).

In order to quantify the genetic contribution to Okinawan longevity, we studied the sibling recurrence risk ratio or "lambda of sib (ls)" in siblings of Okinawan centenarians. This is a calculation that has been shown to give a rough idea of how important genes might be to a given phenotype, such as a disease, or even to something more complex like human longevity. We analyzed a population-based sample of 348 Okinawan centenarians (born between 1874 and 1902) and 969 of their siblings (507 females and 462 males) to explore the feasibility of a genome-wide study of Okinawan longevity. The ls for Okinawan centenarians was 6.5 (95% confidence interval: 3.9-10.7) for females and 5.1 (95% confidence interval: 1.8-14.2) for males, respectively. The weighted sex-combined ls was 6.3. These estimates in Okinawans appear to be higher than those obtained in past work on U.S. Caucasians. For example, a study of the familial component of longevity in Utah families estimated the ls to be 2.3. This suggests an important genetic component to Okinawan longevity and supports further work on the genetics of healthy aging and longevity in this population (see Willcox BJ et al., Substantial advantage for longevity in siblings of Okinawan centenarians. Genetic Epidemiology). 2005;29:286.

Does this mean that Okinawan longevity is all genetic? Not at all. We believe the Okinawans have both genetic and non-genetic longevity advantages -- the best combination. In fact, we have written extensively that the Okinawan traditional way of life -- the dietary habits, the physical activity, the psychological and social aspects, all play an important role in Okinawan longevity. While most studies of humans have suggested that about a third of human longevity is due to genetics, this depends on the age, sex, ethnicity and environment of the study population. For example, studies of "model organisms" of aging, such as rodents, who share many of the same genes as humans, have shown that single genes can influence lifespan by 50% or more. On the other hand, studies of lifestyle interventions, such as eating fewer calories (a.k.a. "caloric restriction") have shown that this dietary intervention can also yield increases in lifespan of a similar magnitude (see Willcox DC et al., Caloric restriction and human longevity: what can we learn from the Okinawans? Biogerontology. 2006;7:173-77). The key is to study both genetic and non-genetic (environmental) factors and ultimately "gene-environment" interactions that lead to healthy longevity. 2. Caloric Restriction, Metabolic Damage and Aging One of the most durable theories of aging is the free radical theory. This theory postulates that damage from free radicals (unstable molecules), generated mainly from metabolizing food into energy, ultimately damages vital body molecules (tissue, DNA, etc.). This damage accumulates with time until, like an old car, we fall apart. In support of this theory, one of the most important findings in free-radical research has been that eating fewer calories increases life span (Sohal RS, et al. Science 1996;273:59-63; Heilbronn LK, et al. Am J Clin Nutr 2003;78:361-9). The initial evidence that this may work in humans has been indirect and based on observation of the low caloric intake of the Okinawans and their long life expectancy (Willcox DC, et al. Biogerontology 2006). More direct evidence suggests that Okinawans following the traditional ways have low blood levels of free radicals. The elders had significantly lower levels of lipid peroxidecompelling evidence that they suffer less free-radical-induced damage. This may indicate healthier lifestyles but may also be due to gene variants that result in lower blood levels of free radicals. This is currently under investigation.

Levels of Lipid Peroxides in Okinawan Centenarians and Septuagenarians Male 100 yo Number 30 of Cases 70 yo 11 Female 100 yo 109 70 yo 18 Total 100 yo 139 70 yo 29

Lipid 1.490.51* 3.150.70 1.721.28* 3.560.81 1.671.16* 3.400.79 Peroxides *p < 0.05 Suzuki M et al. Asia Pac J Clin Nutr. 2001;10(2):165-71 3. Cardiovascular Health and Aging Elderly Okinawans were found to have impressively young, clean arteries, low cholesterol, and low homocysteine levels when compared to Westerners. These factors help reduce their risk for coronary heart disease by up to 80% and keep stroke levels low. Their healthy arteries appear to be in large part due to their lifestyle: diet, regular exercise, moderate alcohol use, avoidance of smoking, blood pressure control, and a stress-minimizing psychospiritual outlook. However, there are also potential genetic aspects such as lower fibrinogen levels possibly due to differences in fibrinogen-related genes. A recent autopsy study that we conducted on a centenarian demonstrated that her coronary arteries were virtually free of atherosclerotic plague (Bernstein, Willcox et al. JGMS 2004).

The chart to the right indicates that the higher the plasma homocysteine (a new risk factor) level is, the more people suffer from cardiovascular disease. Homocysteine is an amino acid that causes damage to arterial walls. It is higher in people who don't get enough folate (e.g. green leafy vegetables) and vitamins B6, B12 but low in Okinawans. 4. Cancer and Aging Okinawans are at extremely low risk for hormone-dependent cancers including cancers of the breast, prostate, ovaries, and colon. Compared to North Americans, they have 80% less breast cancer and prostate cancer, and less than half the ovarian and colon

cancers. Some of the most important factors that may protect against those cancers include low caloric intake, high vegetables/fruits consumption, higher intake of good fats (omega-3, mono-unsaturated fat), high fiber diet, high flavonoid intake, low body fat level, and high level of physical activity. Hormone-Dependent Cancer Risk Yearly Cancer Deaths (per 100,000 people) Location Okinawa Japan Life Expectancy Breast Ovarian Prostate Colon 81.2 79.9 6 11 11 34 37 29 33 3 3 3 10 4 3 7 4 8 4 52 23 20 28 8 16 11 19 17 13 19

Hong Kong 79.1 Sweden Italy Greece USA 79.0 78.3 78.1 76.8

Adapted from World Health Organization 1996; Japan Ministry of Health and Welfare 1996 5. Osteoporosis and Aging

NK, a typical healthy centenarian was reported to be in particularly good health, completely independent, and still farming. He is shown here getting his bone density tested by heel bone ultrasound. Okinawans have about 20% fewer hip fractures than do mainland Japanese, and Japanese have about 40% fewer hip fractures than Americans (Ross PD, et al. Am J Epidemiol 1991;133:801-9). Our research on Okinawan elders showed that their bone density, when adjusted for body size, is similar to Americans, and like the rest of us they continue to lose bone mass as they get older, but possibly at a slower rate. We compared bone mineral density in a group of Okinawans to two groups from mainland Japan and found that by age forty for women and age fifty for men the groups began to

diverge. The Japanese began to lose significantly more calcium from their bones than the Okinawans, suggesting the Okinawans preserve their bone density at healthy levels for longer periods of time than other Japanese (Suzuki M, et al. Japanese J Bone Res 1995;63:166-72). Protective lifestyle factors that may play a role here include high calcium intake by Okinawans in both food and their natural drinking water, high vitamin D levels from exposure to sunlight, increased physical activity, especially at older ages, and high intake of dietary flavonoids (estrogenic compounds from plant foods). 6. Healthy Cognitive Aging and Dementia

Prevalence surveys suggest that the dementia rate is fairly low among the Okinawan elderly, compared to other elderly populations. Even into their late 90s Okinawans suffered lower dementia rates than reported for comparable populations in the United States and elsewhere. 7. The Role of Physical Activity in Healthy Aging

Photo: 97 year old karate master Seikichi Uehara Okinawan centenarians have been lean throughout their extraordinarily long lives, with an average body mass index (BMI) that ranged from 18 to 22 (lean is less than 23). The Okinawans have traditionally kept eating a low-calorie, low glycemic load diet, practicing calorie control in a cultural habit known as hara hachi bu (only eating until they are 80% full), and keeping physically active the natural way. Particular exercise interventions are under study for their role in healthy aging.

8. Women's Health and Aging

Women's health and aging is one of our research interests. For example, women in Okinawa tend to experience menopause naturally and nonpharmacologically with fewer complications such as hot flashes, hip fractures, or coronary heart disease. Lifestyle determinants include diet, avoidance of smoking and exercise in the form of dance, soft martial arts, walking and gardening. Okinawan women also have a very high intake of natural estrogens through their diet, mainly from the large quantities of soy they consume. Soy contains phytoestrogens, or plant estrogens called flavonoids. The other important major phytoestrogens are lignans, which are derived from flax and other grains. All plants, especially legumes (beans, peas), onions, and broccoli, contain these natural estrogens, but not nearly in the same quantity as soy and flax. Recent doubleblind placebo controlled studies support the ability of soy isoflavones to slow the bone loss (Alekel D, et al. Am J Clin Nutr 2001;72:844-52) and hot flashes (Albertazzi P, et al. Obstet Gynecol 1998;91:6-11) that occur with menopause. 9. The Endocrine System, Hormones and Aging Okinawan elders may have higher levels of sex hormones, including natural DHEA, estrogen, and testosterone than similarly aged Americans, suggesting that the Okinawans are physiologically younger. DHEA is a steroid produced in the human adrenal gland, and some studies suggest that it may help ameliorate the ravages of aging. However, taking DHEA supplements could increase risk for breast and other cancers so we do not recommend taking DHEA supplements. More supported by the scientific literature is that DHEA levels decline in direct ratio with age, so it may be a good marker of biological age. Okinawans appear to have higher DHEA levels than similarly aged Americans suggesting that Okinawans may age slower than Americans. As Okinawans age, both sexes maintain remarkably higher levels of estrogen which may help protect against heart disease and osteoporosis. Testosterone is the male equivalent of estrogen. Higher endogenous levels increase our muscle mass and our body hair, deepen our voices, and control our libidos, among other functions. This hormone also appears higher in older Okinawan men. Cross-national population studies are needed to confirm these differences and their biological significance.

Sex Hormones in Okinawans and Americans Age Group (years) DHEA (ng/mL) Testosterone (ng/dL) 439 314 298 Estrogen (pg/mL) 35.7 20.6 12.1

Okinawan men 70 y 2.6 American men 70 y 2.0 Okinawan men 100 0.8 y

Okinawan women 70 y American women 70 y Okinawan women 100 y

3.0

13

15.5

1.1

17

5.5

0.6

39

4.2

Normal ranges for these age groups

M 0.5-5.5 M 240-950 F 0.3-4.5 F 20-80

M 0-50 F 0-35

Source: Suzuki M., et al. Centenarians in Japan. Tokyo, Japan:Nakayamashoten 1995:64-78. Okinawa Centenarian Study. All Rights Reserved.