Extreme Longevity in Dominica, West Indies: A Population Study

Noel T. Boaz, Ph.D., M.D.Gerald A.C. Grell, M.D., FRCP, FACPRobert Nasiiro, M.D., M.P.HPaul Ricketts, MB.BS., M.Sc.

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 1979Prior 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)

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

Dominica

Geography: 290 mi2 island in the Lesser Antilles of eastern Caribbean; mountainous terrain, largely forested, with numerous riversPopulation: 72,727 (May, 2001 census); Largest Caribbean enclave of Carib Amerindians; Large population of African descent; Small European population; Admixture among allLife Expectancy: Male - 75 years; Female - 78 to 81 yearsLanguages: French creole (“patois”), English, pidgin English (“kokoi”), Carib/Arawak (extinct)

= centenarian

Centenarians are evenly distributed geographically

Physiography

South fork, Layou River, central Dominica, north of Morne Trois

Pitons

Pointe Daniel, Southeastern Atlantic coast

Carib Reserve, northeastern Dominica, looking west towards Morne Diablotins (el.

1747 ft.)

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

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

U.K. passport accepted as documenting a birth date as April 2, 1898

Chair scale for individuals

unable to stand unassisted

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

Methods: Lens Pachymetry

For consenting subjects – Ultrasound A-scan immersion biometry using a Kohn shell Database will relate lens thickness to age

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

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

Dominica Centenarian Statistics

Female Male Total

Make-Up by Gender

86% (N=19)

14% (N=3)

100% (N=22)

Mean Age

102.1 102.3 102.1

Mean BMI 20.5 17.0 19.0

Married 95% (N=18)

100% (N=3)

96% (N=22)

Children 6.7 (N=18)

4.7 (N=3)

6.1 (N=22)

Functional Independence: Mr. WJF

Age 102 years (birth date May 12, 1900) documented by baptismal certificateWork: fisherman (rowed 30 miles round trip to Roseau weekly)25 pack-year smoking historyBlood pressure 144/70Katz rating: ARDRS-2 Rating: 23

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 Scores - Dominica Centenarian Study

0

1

2

3

4

5

6

A B C D E F G Other

Scores

Nu

mb

er

of In

div

idu

als

Mid-poin

t

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).

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

Cardiovascular Fitness and Strength: Mr. WE

Born 15 August, 1898, documented by family Bible and government records; age now 105Occupation: 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 headBlinded when cement mix got into eyes in 1972Never hospitalized; denies use of tobacco or alcoholBP 133/69BMI 16.3Independent: Katz “Other”, RDRS-2 30

Man, age unknown, carrying 75-pound load of wood in Carib Reserve, Dominica, 12/2001

“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.

1. 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.

2. Burkitt, D.P. 1973 Some diseases characteristic of modern western civilization: A possible common causative factor. Clin. Radiol. 24:271-280.

Dominica Centenarian medical conditions contrast markedly with U.S. and other Caribbean “diseases of civilization”

01020304050607080

Percentage

HTN

Oste

o

Cat/

Gl/M

D

DJD/

OA

Hype

rCho

DM

Canc

er

TIA/

CVA

Diseases

Dom Cent

Dom Elder

Barb Elder

US-Glennan

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, fitnessOsteoporosis 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 stressU.S. cancer and hypercholesterolemia prevalences are high compared to Caribbean; Factors: diet, toxins, exerciseBlindness (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.)

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.

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); breadFruits/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, cressFish/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

Possible “Canalization Factors”: Low Rate of Tobacco Use

70% (14/20) deny any use of tobacco 15% (3 females) habitually smoked a pipe15% smoked cigarettes – two 8.5 and 15.5 pack/years, and one at 66 pack/years Cigarette smoking is not generally popular in Dominica

Possible “Canalization Factors”: Low Rate of Alcohol Use

65% (N=13) deny any use of alcohol25% (N=5) drink occasionally, on special occasions, and/or with meals5% (N=1) drank when young but claims to have stopped at age 405% (N=1) admits regular use of alcohol

Summary: “Canalizing Factors” Postulated as Important to Longevity Among Dominica Centenarians

Active, athletic life-style: Lifelong cardiovascular fitness, low BMI, muscularityDiet: 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 pollutionLow stress: Low population density, no crowding, access to forest, river, and marine resources Low rates of tobacco and alcohol useEffective public health and medical care: Present on Dominica and explain low incidence of infectious and parasitic diseases

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

ShorteningGenetic 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