According to recent studies, adopting a healthy lifestyle, i.e., eating well, exercising, managing stress, and not smoking or drinking too much alcohol, has beneficial effects on the aging of our cells. One of the well-documented phenomena that occur during cellular aging is the degradation of telomeres, unique structures found at the ends of each of our chromosomes; however, a healthy lifestyle can slow down this process
Telomeres and aging
Telomeres are repetitive DNA structures, shaped like a “hairpin”, found at both ends of chromosomes and that ensure the integrity of the genome during cell division. At each division, the telomeres shorten until they become too short to fulfill their protective function: the cell can no longer divide and enters senescence, then dies. Telomere shortening is countered by the action of telomerase, an enzyme that lengthens telomeres during each DNA replication. Telomere shortening in peripheral blood mononuclear cells (lymphocytes and monocytes) is associated with aging and aging-related diseases such as cancer, stroke, dementia, cardiovascular disease, obesity, osteoporosis and type 2 diabetes. Leukocyte telomere length is significantly, albeit weakly, associated with mortality, but cannot predict survival as well as other variables (age, mobility, cognition, smoking, daily life activities).
Physical training improves many aspects of human health, including exercise capacity, blood pressure regulation, insulin sensitivity, lipid profile, reduction of abdominal fat and inflammation. These beneficial effects contribute to increased endothelial function, delay the progression of atherosclerotic lesions, and improve collateralization of blood vessels in people with type 2 diabetes, coronary artery disease and heart failure. The underlying mechanisms are known in part, but details at the molecular level are less well known and are the subject of much research.
The process of cellular aging can be slowed down by sustained exercise. A study published in 2009 showed that sustained physical training in young and middle-aged athletes was associated with higher telomerase activity, increased expression of telomere-stabilizing proteins, and longer telomeres, compared to sedentary people.
The same research group recently conducted a randomized controlled trial to demonstrate that exercise is the cause of increased telomerase activity and telomere length. The results of the study were published in 2018 in the European Heart Journal. The researchers recruited 124 middle-aged men and women (≈50 years) who were in good health, but did not exercise. During the six-month study, participants were randomly divided into four groups: a control group and three groups that did different types of exercise 3 times a week; one group did endurance training (walking/running, 45 min/day); another group exercised at high intensity intervals (4 min at high intensity/4 min rest, repeated 4 times); and the third group did resistance exercises (various weight machines). Blood samples were taken before, during, and at the end of the study to measure telomere length and telomerase activity in leukocytes (white blood cells).
At the end of the study, those who exercised, regardless of the type, had better cardiorespiratory capacity than at the beginning of the study. Telomerase activity was 2–3 times higher in the leukocytes of those who did endurance or interval exercises, compared to the control group. However, this effect was not observed in people who did resistance exercises (weight training). Similarly, telomere length was greater in those who did endurance or interval exercises, but not in those who did resistance exercise.
These results suggest that endurance exercises such as running, brisk walking or swimming are more effective than resistance exercises to keep longer telomeres and delay cellular aging. It should not be concluded, however, that resistance exercises are useless for healthy aging. Resistance exercises increase overall fitness, which is one of the most important indicators of longevity. The researchers suggest further study on the effects of various combinations of endurance and resistance exercises on cellular aging. The lead author concludes that the central message of his study is that it is never too late to start exercising and that it will have beneficial effects on aging.
Proteomic approach to the effects of exercise
Researchers have studied the effects of endurance exercise on the expression of 1,129 proteins in the blood plasma (plasma proteome), classified into 10 modules or patterns according to their level of interconnection. Exercise altered protein expression of four modules in young men, and five modules in older men. Modules affected by the exercise included proteins related to signalling pathways involved in wound healing, apoptosis (cell death) regulation, glucose, insulin and cellular stress signalling, as well as immune and inflammatory responses. In addition, several exercise-affected modules could be correlated with physiological and clinical indicators of a healthy life, including diastolic blood pressure, insulin resistance, maximal aerobic capacity, and vascular endothelial function.
According to a systematic review of studies published on the subject, five studies indicate that fruit and vegetable consumption is associated with longer telomeres, while eight other studies have not identified a significant association. For foods other than fruits and vegetables, including grains and meats, the data are inconclusive as a whole. Some studies, however, indicate unfavourable associations between certain food groups and the length of telomeres: grains, processed meats, sugary drinks, fats and oils. With regard to eating habits, only the Mediterranean diet has been associated with longer telomeres, but not in all the studies published to date. Future larger-scale observational studies and more focused randomized controlled trials could help to better identify which elements of the diet are beneficial for telomere maintenance and help slow the process of cellular aging.
Effect of stress
Several cross-sectional studies have reported associations between telomere stability and stress exposure (review articles here, here and here). The association lasts throughout life and has been observed in children whose mothers had been under significant stress. It seems that even prenatal stress indirectly experienced by the fœtus is associated with shorter telomeres after birth. Prolonged or repeated exposure to stress is associated with a shortening of telomeres and the development of age-related diseases such as type 2 diabetes, heart disease, dementia and osteoarthritis. According to some studies, people with bipolar disorder, schizophrenia, major depression and post-traumatic stress disorder have shorter telomeres. Stress and mental illnesses therefore have direct effects on the aging of our cells, with consequences for health over the course of life.
For men diagnosed with low-grade prostate cancer, adopting a completely different and healthy lifestyle (plant-based, low-fat diet, exercise, stress management, social support) has been associated with a 10% increase in telomere length in their lymphocytes and monocytes, five years after the start of the intervention. Participants in the control group (active surveillance only), on the contrary, saw the average length of their telomeres decrease slightly (-3%). This intervention study included only a small group of people (n = 30), so larger-scale randomized controlled trials are needed to confirm these findings.
There is growing evidence that physical activity has a significant influence on health and quality of life as people age. For example, older people who exercise regularly are often in better shape, they are more muscular, and they are less likely to develop chronic illnesses or physical disabilities than sedentary seniors. Adopting a lifestyle that combines healthy eating, regular exercise and stress management is certainly one of the best things one can do to prevent or fight age-related diseases.
Updated May 23, 2018
Nitrates (NO3–) and nitrites (NO2–) are mostly known to the public as undesirable residues of the agri-food chain as they are associated with potentially carcinogenic effects. Yet, these molecules are naturally found in fruits and vegetables (nitrates) as well as in the human body (nitrates and nitrites) where they contribute to important physiological functions, particularly in the cardiovascular system. Moreover, it has now been proven that dietary nitrates can be beneficial to cardiovascular health and sports performance, as will be discussed below.
Nitrates and Nitrites: Dangerous or Harmless?
During the curing process used to transform meats into charcuterie (ham, sausages, bacon, etc.), nitrite salt is added to stabilize the colour and taste of meats and to prevent the development of pathogenic microorganisms. Nitrite salt is in fact very effective in preventing the proliferation of bacteria, including the formidable Clostridium botulinum, which produces a powerful toxin that causes botulism, a very serious, sometimes deadly, paralytic illness. Nitrates and nitrites themselves are not carcinogenic; rather, it is N-nitroso compounds, such as nitrosamines, produced by the reaction between nitrites and meat protein that are. The curing process promotes the formation of nitrosamines due to the abundance of added nitrites, proteins and myoglobin whose heme group accelerates the reaction. Cooking at high temperatures (deep-frying) greatly accelerates the formation of nitrosamines. Government regulations limit the quantity of nitrites used to cure meats and requires the addition of neutralizing agents (antioxidants) in certain products, for example bacon. Nitrates naturally present in food mainly come from fruits and vegetables, which contain antioxidants, such as vitamin C and polyphenols that prevent the formation of N-nitroso compounds.
Up until about twenty years ago, nitrates and nitrites found in the human body were considered inert final products of the metabolism of nitric oxide (NO), a gas that acts as a signalling molecule and contributes to the regulation of blood flow and several other physiological functions. In the presence of oxygen, nitric oxide is produced in the endothelial cells that line blood vessels through the oxidizing reaction of the amino acid L-arginine into NO and L-citrulline. Several medications used to treat heart disease increase the signalling pathway of NO, either by increasing its bioavailability or by inhibiting its degradation. The most well-known are organic nitrates (e.g. nitroglycerine). They act by releasing NO rapidly and induce non-specific dilatation of both arteries and veins, which improves blood flow. Other pharmacological agents are phosphodiesterase-5 inhibitors, which are used to treat pulmonary hypertension and erectile dysfunction (e.g. sildenafil, better known by the brand name Viagra). Moreover, inhibitors of the HMG reductase enzyme (statins) and of the angiotensin-converting enzyme indirectly increase the bioavailability of NO.
Since 2001, we know that endogenous nitrites are an important alternative source of NO, particularly when oxygen levels are low, as is the case with blood microcirculation (see Figure 1). At that time, it was thought that the intake of nitrates and nitrites from food sources had no effect on blood vessels, since it was not thought that this intake could increase the circulating concentration of nitrites. We now know that dietary nitrates are quickly absorbed in the small intestine, about 75% of nitrates are excreted by the kidneys, and what is left becomes highly concentrated in the salivary glands (10 times the plasma concentration). When nitrates are secreted in saliva, they are converted to nitrites by the commensal bacteria, then swallowed with the saliva and absorbed into intestinal circulation. The circulating nitrites can be transformed into nitric oxide by different enzymes (reductases).
Figure 1. Formation and recycling of nitrates (NO3–), nitrites (NO2–) and nitric oxide (NO). Adapted from Woessner et al., 2017. In the presence of oxygen, endothelial nitric oxide synthase (eNOS) catalyzes the oxidation of L-arginine to NO. NO can also be quickly oxidized into nitrites and nitrates. A secondary source of vascular NO is obtained through diet. Consumption of foods high in inorganic nitrates (green leafy vegetables, beetroot) has been shown to increase plasma nitrate concentration,which can be secreted in saliva and reduced to nitrite by commensal bacteria in the mouth. Nitrites can then be further reduced to NO (and other biologically active nitrogen oxides) via several mechanisms that are expedited under hypoxic conditions. Hence, although some of the circulating nitrates and nitrites are excreted in the kidneys, they can also be recycled back to NO.
Dietary Sources of Nitrates
About 85% of dietary nitrates (NO3–) come from vegetables, and the rest mostly from drinking water. Dietary nitrites (NO2–) mostly come from cured meats (charcuterie). Vegetables can be grouped into 3 categories according to their nitrate content (see Table I). Vegetables high in nitrates (>1000 mg/kg) belong to the Brassicaceae (arugula), Chenopodiaceae (beetroot, spinach), Asteraceae (lettuce), and Apiaceae (celery) families. Most commonly eaten vegetables have medium levels of nitrates (100–1000 mg/kg), whereas onions and tomatoes contain very little nitrates (<100 mg/kg). Juicing vegetables is a popular and convenient way to increase vegetable consumption, and several commercial juices are available on the market. Whereas the nitrate content of homemade fresh juice is negligible, it increases dramatically after two days at room temperature, but remains low if stored in the refrigerator at 4 °C. The conversion of nitrates to nitrites in juices prepared at home is due to the presence of bacterial enzymes (reductases), which is less problematic in commercially prepared juices since they are lightly pasteurized.
Table I. Nitrate content in vegetables and water. Source: Lidder & Webb, 2012.
*Note: To facilitate the selection of vegetables to build a diet, the authors recommend using “nitrate units” (1 unit = 1 mmol) to ensure sufficient nitrate intake in order to benefit from the hypotensive effects or to improve exercise performance, and also to avoid consuming more nitrates than recommended (4.2 units for an adult weighing 70 kg).
The acceptable daily intake (ADI) established by the European Food Safety Authority for nitrates is 3.7 mg/kg (0.06 mmol/kg), which corresponds to about 260 mg (4.2 mmol) daily for an adult weighing 70 kg. This ADI was established by dividing the maximum harmless dose for rats and dogs by 100. According to estimations, Europeans consume 31–185 mg of nitrates daily and 0–20 mg of nitrites daily. Based on the moderate recommendation to eat 400 g of a variety of fruits and vegetables per day, the dietary intake of nitrates is about 157 mg/day. Several countries currently recommend a diet high in nitrates for people with heart disease. The DASH diet (Dietary Approach to Stop Hypertension), for example, with its emphasis on fruits and vegetables, whole grains, lean meats (poultry, fish) and nuts, provides a significant level of nitrates. In a clinical study, the DASH diet (rich in fruits and vegetables) lowered blood pressure in subjects with hypertension almost as much as a monotherapy with antihypertensive medication. In fact, it has been suggested that the cardioprotective effects of fruits and vegetables observed in epidemiological studies are caused by the high nitrate content of green leafy vegetables.
The choice of fruits and vegetables eaten can have an important impact on the quantity of dietary nitrates. For example, it is estimated that a DASH diet that only includes fruits and vegetables with low nitrate levels would provide 174 mg of nitrates and 0.41 mg of nitrites, whereas choosing fruits and vegetables high in nitrates can provide up to 1222 mg of nitrates and 0.35 of nitrites. This estimation indicates that the dietary intake of nitrates can vary up to about 700%, according to dietary choices. An excessive intake of nitrates, which is very rare, can cause methemoglobinemia, a disease or intoxication where the level of methemoglobin (a type of hemoglobin that cannot bind oxygen) is too high. Infants (<3 years) are much more susceptible than older children and adults to this disease. In children it is sometimes called “blue baby syndrome.” In adults, this intoxication is rare because their diet cannot contain nitrates in high enough quantities to cause the disease. However, infants can get sick by consuming 200 g of spinach high in nitrates/per day. The American Academy of Pediatrics recommends not giving children foods (purees) containing vegetables (e.g. spinach, beetroot, green beans, carrots) before the age of three months.
A prospective study published in 2018 revealed an association between urinary nitrate and the prevalence of heart disease and the risk of mortality. A concentration of nitrates in urine that was 10 times higher was associated with a 33% decreased risk of hypertension and a 39% decreased risk of stroke. However, there was no association between the concentration of nitrates in urine and the risk of myocardial infarction. Moreover, a ten-fold increase of urinary nitrates was associated with a reduction in all-cause mortality (–37%) and a reduction in cardiovascular mortality (–56%). Despite concerns that nitrates can be converted to nitrites and N-nitrosamines and become carcinogenic, nitrates in urine were not associated with cancer prevalence or cancer mortality. Future studies should evaluate whether nitrate supplements can prevent or reduce the prevalence of heart disease and premature death.
The Effect of Nitrates on Blood Pressure
A study published in 2008 (randomized, placebo-controlled, crossover design) evaluated the effects of a diet high in nitrates on blood pressure in healthy, non-smoking and physically active participants. A diet high in nitrates led to a significant decrease in average blood pressure (3.2 mm Hg) and diastolic blood pressure (3.7 mm Hg), when compared to a diet low in nitrates. In this study, the daily dose of nitrate supplements taken corresponded to that normally contained in 150–250 g from vegetables high in nitrates, such as spinach, beetroot and lettuce. The authors note that the decrease in blood pressure observed in their study was similar to that observed in the DASH study in the healthy group that ate a diet rich in fruits and vegetables, when compared with the group that consumed few fruits and vegetables. In another study, drinking 500 ml of beetroot juice led to an even more significant decrease in systolic (~10.4 mm Hg) and diastolic (~8 mm Hg) blood pressure, when compared to the group that ingested the placebo (500 ml of water, crossover study). This effect was temporally correlated with the transient increase in plasma nitrite concentration. Interrupting the enterosalivary conversion cycle of nitrates to nitrites (by asking participants to spit out all their saliva for 3 hours after ingesting beetroot juice) completely prevented the increase of plasma nitrite concentration, and the decrease in blood pressure. This latter finding confirms that the decrease in blood pressure caused by the consumption of beetroot juice is due to the conversion of nitrates found in beetroot juice to nitrites.
Hypertension, Type 2 Diabetes, Hypercholesterolemia, Obesity
Even though the effect of nitrates on the decrease in blood pressure in healthy subjects was consistently reported in several studies, this is not always the case in studies among subjects with a chronic disease. In a British study of 68 subjects with hypertension, the blood pressure of those who drank 250 ml of beetroot juice daily for a month was lower by 8 mm Hg, compared to those who consumed beetroot juice depleted of nitrates (placebo). In a similar study, also among hypertensive subjects, no decrease in blood pressure was observed, even though the consumption of beetroot juice resulted in a considerable increase in plasma nitrite concentration. In another study of diabetics, there were no effects of dietary nitrites (beetroot juice) on blood pressure, endothelial function, and insulin sensitivity. However, supplementing the diet with beetroot juice significantly reduced systolic blood pressure of overweight or obese participants, aged 55 to 70, when compared to supplementation with blackcurrant juice, which was very low in nitrates. Finally, a study among 69 participants with hypercholesterolemia showed that the intake of dietary nitrates improved vascular function when compared to the group that received the placebo. The reason for variability of the results obtained in these clinical studies is unknown. Length of the treatment, medications used to manage hypertension, methods used to measure blood pressure, and differences between cohorts (e.g. age, BMI, diminished response to NO in certain diseases) are among possible explanatory factors.
A recent study (randomized, placebo-controlled, crossover design) shows that dietary nitrate supplementation (beetroot juice) increases exercise performance in people with heart failure with reduced ejection fraction. Here is a summary of the study and the main results. After consuming 140 ml of concentrated beetroot juice, the plasma nitrate and nitrite concentration of subjects increased on average by 15 times (1469%) and 2 times (105%), respectively, and the concentration of nitric oxide (a gas) in breath increased by 60%. This effect was not observed with the placebo, a beetroot juice previously depleted of nitrates and that could not be differentiated from the original beetroot juice (packaging, colour, texture, taste and smell) by the study subjects. Two hours after consuming the beetroot juice, subjects exercised for a few minutes on an ergometer stationary bike in a semi-reclined position at various intensities. Respiratory gas exchange was measured continuously. Heart rate, blood pressure and perceived fatigue were evaluated during the last 30 seconds of each phase. Consumption of nitrates had no effect on the ventilatory response, or exercise efficiency, heart rate, and blood pressure. However, compared to the placebo group, the subjects that ingested the beetroot juice were able to reach peak oxygen consumption (VO2 peak) that was higher by 8%, and increased, on average, their duration of effort to exhaustion by 7%. These findings suggest that dietary nitrate intake could be a valuable addition to the management of exercise intolerance among patients with heart failure with reduced ejection fraction.
Nitrates and Athletic Performance
Several studies have been conducted on the impact of nitrate supplementation on the performance of amateur and competitive athletes. In one study, 10 young men drank concentrated beetroot juice or a placebo and, after 2.5 hours (to coincide with the maximum concentration of circulating nitrites), did moderate to high intensity physical activity. When compared to the placebo group, consuming 70 ml of beetroot juice had no effect on athletic performance, but ingesting 140 ml or 280 ml of juice reduced oxygen consumption during moderate physical activity by 1.7% and 3.0%, whereas average time–to-task failure(at very high intensity) increased from 8 min 18 s to 9 min 30 s (14%) and from 8 min 13 s to 9 min 12 s (12%), respectively. Such an increase (12–14%) can seem enormous, but in fact translates to about a 1 to 2% reduction in time to complete a race, for example. In an elite sport, a 1% difference is considered very significant, reducing the time it takes to race a 1,500-metre distance by about 2 seconds and that of a 3,000-metre distance by about 4–5 seconds, for example. Other studies have shown a reduction in oxygen consumption (for the same effort) and an improvement in performance for walking, running, rowing, and cycling, through nitrate supplementation (beetroot juice or NaNO3–). A meta-analysis of 17 of these studies shows that nitrates give a small advantage in performance for time to exhaustion tests, and have a slight beneficial, but not statistically significant, effect on performance during time trials. Another meta-analysis, published in 2016, including 26 randomized, placebo-controlled studies, indicates that nitrate supplementation significantly reduces oxygen consumption for a given effort during a moderate to high intensity exercise in healthy individuals, but not in people with a chronic disease.
Beetroot juice and other supplements with high nitrate levels are obviously not a cure-all. It is better to adopt a global approach to stay healthy, i.e. exercise daily and follow a healthy diet (Mediterranean for example) and eat several servings of fruits and vegetables every day, including green vegetables rich in nitrates, fibre, minerals and vitamins.