Extreme Longevity in Dominica, West Indies: A Population Study

1. Extreme Longevity in Dominica, West Indies: A Population Study Noel T. Boaz, Ph.D., M.D. Gerald A.C. Grell, M.D., FRCP, FACP Robert Nasiiro, M.D., M.P.H Paul Ricketts, MB.BS., M.Sc.

2. Was “Ma Pampo” Really 128 Years Old? • Was Mrs. Elizabeth Israel (“Ma Pampo”), possibly the oldest living individual in the world (b. 27 I, 1875; d. 14 X, 2003), an isolated occurrence, or is extreme longevity relatively common on Dominica? • Certificate of Birth fulfills requirements of study, but original Portsmouth Catholic Church records destroyed by Hurricane David in 1979, and original governmental birth records destroyed by fire in 1979 • Prior oldest living human being was Jeanne Calment of Arles, France, who died at the age of 122 years (b. 21 II, 1875, d. 4 VIII 1997)

3. Dominica Centenarian Study • Retrospective Cohort Study – • Report on 1st year of 3-year study: 1 Sept, 2001 to 30 Aug, 2004 • “a scientific research project aimed at discovering the biological and medical causes of long life. It also seeks to provide ongoing medical surveillance for health maintenance of the elderly, especially centenarians, on Dominica.” • Observance of human rights per Helsinki Accord: • Ross University School of Medicine Human Subjects Review Board • Dominica Council on Ageing • Dominica Ministry of Community Development and Gender Affairs • Dominica Office of the President • Consent of subjects to participate: • Verbal agreement with subjects and care-givers • Signed “Participant Authorization Form”, with options for four levels of participation • Medical history and access to medical records • Physical examination • Laboratory analysis of blood, hair, or skin cells • Laboratory analysis of tissues at autopsy

4. Dominica Geography: 290 mi2 island in the Lesser Antilles of eastern Caribbean; mountainous terrain, largely forested, with numerous rivers Population: 72,727 (May, 2001 census); Largest Caribbean enclave of Carib Amerindians; Large population of African descent; Small European population; Admixture among all Life Expectancy: Male - 75 years; Female - 78 to 81 years Languages: French creole (“patois”), English, pidgin English (“kokoi”), Carib/Arawak (extinct) = centenarian Centenarians are evenly distributed geographically

5. Physiography Pointe Daniel, Southeastern Atlantic coast South fork, Layou River, central Dominica, north of Morne Trois Pitons Carib Reserve, northeastern Dominica, looking west towards Morne Diablotins (el. 1747 ft.)

6. Research Design • A “natural history” approach, investigating the phenomenon at a populational level, using the following perspectives: • Ecological - Documenting the environmental, nutritional, demographic, familial, and sociocultural contexts • Evolutionary - Biological, genetic, and adaptive contexts • Comparative - Dominica centenarians compared to studies elsewhere • Results will help define what is “adaptively normal” (Boaz, N.T. 2002 Evolving Health. NY: Wiley), a fundamentally important concept for medicine

7. Methods: Documenting the Phenomenon • In visits to each centenarian • Photographing of subjects and their birth documents • 4-page form recording • Health history • Data for assessment scales (ADL’s) • Weight • Height • Blood pressure • Other information Van at Vielle Case Health Centre Chair scale for individuals unable to stand unassisted U.K. passport accepted as documenting a birth date as April 2, 1898

8. Methods: Tissue Collection Blood samples are frozen and curated for genetic analysis Postmortem examination yields organ tissue samples for analysis and to determine cause of death

9. For consenting subjects – Ultrasound A-scan immersion biometry using a Kohn shell Database will relate lens thickness to age Methods: Lens Pachymetry

10. Results: Extreme Longevity in Dominica • Dominica has 22 confirmed centenarians (excluding “Ma Pampo”) in a population of 72,727 (May, 2001 census) • Prevalence is 3.02/10,000, over 3 times the incidence of centenarians in Western countries (Perls, T. 1995 Sci. Am. 272:7-75). •  1/10,000 from Boston, Danish, French, and Italian Centenarian Studies • Prevalence is similar to extreme longevity seen in Okinawa and Sardinia Centenarian Mrs. FJ with Dr. G.A.C. Grell

11. Population Statistics - Dominica • Population growth rate -1.14% (2000 est.) • Birth rate  18.27 births/1,000 population (2000 est.) • Death rate  7.3 deaths/1,000 population (2000 est.) • Net migration rate  -22.39 migrant(s)/1,000 population (2000 est.) • Emigration of young Dominicans results in lower overall population census, thus increasing apparent prevalence of centenarians

12. Dominica Centenarian Statistics

13. Functional Independence: Mr. WJF • Age 102 years (birth date May 12, 1900) documented by baptismal certificate • Work: fisherman (rowed 30 miles round trip to Roseau weekly) • 25 pack-year smoking history • Blood pressure 144/70 • Katz rating: A • RDRS-2 Rating: 23

14. Measures of Function – Katz Index • Katz Index of Independence in Activities of Daily Living (ADLs) • Loss of ADLs in old age presumed to be in reverse ontological order and due to neurological damage or advancing age (Guttman Scale) • 50% of the Dominica centenarian population scored “E” or better Katz Rankings from A – independent, to G – totally dependent • A second index, the Rapid Disability Rating Scale, assess ADL’s without an assumption of ontogenetic order • Average of the Dominican centenarians is 41, compared to 21-22 for community-dwelling older adults, 32 for hospitalized older adults, and 36 for nursing home residents(Kane and Kane 2000 Assessing Older Persons. Oxford Univ. Press, p. 33). Mid- point

15. Leanness: Mrs. AT • Mean BMI of Dominica centenarians is 19 • Mrs. AT, Soufriere, Dominica, b. 6 IX 1900; d. 7 V 2002 • BMI = 13.7 • Katz rating G • RDRS-2 = 60 Loss of dentition, difficulty in preparing traditional, non-Western foods, or inability/unwillingness/lack of knowledge of caretakers in preparing traditional food may place centenarians at nutritional risk

16. Cardiovascular Fitness and Strength: Mr. WE • Born 15 August, 1898, documented by family Bible and government records; age now 105 • Occupation: Sawyer. Used cross-cut saw 10 hours a day in montane forests; week-long stays in the forest, and carried out heavy loads of sawed lumber on head • Blinded when cement mix got into eyes in 1972 • Never hospitalized; denies use of tobacco or alcohol • BP 133/69 • BMI 16.3 • Independent: Katz “Other”, RDRS-2 30 Man, age unknown, carrying 75-pound load of wood in Carib Reserve, Dominica, 12/2001

17. “Diseases of Civilization” are Rare in Dominica Centenarians • Common complaints • Osteoarthritis (OA)/Degenerative Joint Disease - most common • Immobility • Blindness (accident, glaucoma, cataracts, or macular degeneration) • Urinary incontinence (females) • Results of trauma/old injuries – common • Rare complaints: • Hypertension (HTN) • Stroke • Dementia (vascular) – Alzheimer’s not seen • Cardiac arrhythmia • Diabetes mellitis (DM) • Osteoporosis • Cancer • Dominica centenarians resemble a “pre-Second Epidemiologic Transition” population1, i.e. before a shift from acute infectious diseases to chronic noninfectious, degenerative diseases2 except that good public health and access to health care in Dominica reduce infectious and parasitic disease. • Armelagos et al. 1998 Disease in Human Evolution. In: Selig, R.O. and M.R. London, eds. Anthropology Explored, pp. 96-105. Washington, DC: Smithsonian Institution Press. • Burkitt, D.P. 1973 Some diseases characteristic of modern western civilization: A possible common causative factor. Clin. Radiol. 24:271-280.

18. Dominica Centenarian medical conditions contrast markedly with U.S. and other Caribbean “diseases of civilization” • Dominica centenarians have a low incidence of HTN, TIA/CVA, and diabetes mellitis, both for their population and in comparison with U.S. geriatric patients, despite being a population at risk (African American); Factors: exercise, diet, fitness • Osteoporosis is rare among Dominica centenarians, but osteoarthritis/DJD is the most common ailment; trend is opposite in U.S. sample; Factors: strength, weight bearing, joint stress • U.S. cancer and hypercholesterolemia prevalences are high compared to Caribbean; Factors: diet, toxins, exercise • Blindness (cataracts, glaucoma, macular degeneration) prevalences similar across samples, where measured US-Glennan = Glennan Center, EVMS geriatric patients > 85 years of age (N=36); Anonymous data courtesy of Rosanne Newman, M.D. Dom Elder = Marigot Health District, Dominica; individuals > 65 yo (N=132) (Veen-de Vries, N.R., et al. 1999 Health Status of the elderly in the Marigot District. In: Luteijn, A.J. (ed.) Primary Health Care in Dominica: Studies in the Marigot Health District, pp. 113-125, Groningen: Regenboog.) Barb Elder = Diagnoses of patients at Geriatric Hospital, Barbados from Fraser. (Grell, G.A.C. 1987 The Elderly in the Caribbean, p. 8. Kingston, Jamaica: University Printery.)

19. Do “canalizing environmental factors” explain Dominica longevity? 1Corruccini, R.S., and S.S. Kaul 1983 The epidemiological transition and anthropology of minor chronic non-infectious diseases. Med. Anthropol. 7:36-50.

20. Possible “Canalization Factors”: Traditional Diet in Dominica • Staples – Tubers/ “ground provisions”: yams (Dioscorea batatas), dasheen/tanya (Clocasia esculenta); also plantains (Musa sp.) and breadfruit (Artocarpus altilis); bread • Fruits/Vegetables - Grown locally: mangoes (Mangifera indica), citrus (Citrus paradisi, Citrus sinensis, Citrus reticulata, Citrus aurantifolia), papaya (Carica papaya), pineapple (Ananas comosus), bananas (Musa acuminata), pomegranate (Punica granatum), soursop (Annona muricata), melons (Citrullus lanatus), squash (Cucurbita pepo) / lettuce, tomatoes, onions, spinach, cress • Fish/Crustaceans - Land crabs (Cardisoma guanhumi), river fish (many species), sea fish (many species), spiny lobster (Panulirus argus), crayfish (Orconectes neglectus) • Land vertebrates – Agouti (Dasyprocta leporina), chicken, frogs (“crapaud” or “mountain chicken”), manicou opossum (Didelphis albiventris), pork, goat; rarely beef • Sweeteners - Molasses; brown (unrefined) sugar; rarely white (refined) sugar • Drinks - Water, coffee, herbal teas, rum; wine and brandy only in some locales

21. Possible “Canalization Factors”: Low Rate of Tobacco Use • 70% (14/20) deny any use of tobacco • 15% (3 females) habitually smoked a pipe • 15% smoked cigarettes – two 8.5 and 15.5 pack/years, and one at 66 pack/years • Cigarette smoking is not generally popular in Dominica

22. Possible “Canalization Factors”: Low Rate of Alcohol Use • 65% (N=13) deny any use of alcohol • 25% (N=5) drink occasionally, on special occasions, and/or with meals • 5% (N=1) drank when young but claims to have stopped at age 40 • 5% (N=1) admits regular use of alcohol

23. Summary: “Canalizing Factors” Postulated as Important to Longevity Among Dominica Centenarians • Active, athletic life-style: Lifelong cardiovascular fitness, low BMI, muscularity • Diet: High-fiber, low salt, low sugar, high protein, many fresh fruits, root staples; similar to “Paleo-diet” (Eaton et al. 1985) • High environmental quality: Low exposure to toxins, no air pollution, no water pollution, no noise pollution • Low stress: Low population density, no crowding, access to forest, river, and marine resources • Low rates of tobacco and alcohol use • Effective public health and medical care: Present on Dominica and explain low incidence of infectious and parasitic diseases

24. Remaining Questions and Future Research • How to assess age without written records? • Anatomical Assessment of Extreme Longevity – Lens Pachymetry • Cellular Assessment of Extreme Longevity - Telomere Shortening • Genetic Aspects of Dominica’s Centenarians: Are they related? Do they share “anti-aging genes”? Do they lack “aging genes”? • In Dominica Centenarian Study, the following argue against primary genetic effects: • Centenarians are unaware of any kinship with other centenarians • Centenarians were born and live throughout the island • Centenarians come from different populational/racial backgrounds, e.g. Carib Amerindian, African American, Afro-European • Population structure is derived from widespread Carib and African American influx over 400 years, along with European admixture, not conducive to inbreeding