ENHANCING PHYSIOLOGIC AGE/RESTLESS LEGS
From the American Academy of Family Physicians’ 2006 Scientific Assembly, Washington, DC
| LIFESTYLE PROGRAM TO ENHANCE PHYSIOLOGIC AGE —Steven C. Masley, MD, Assistant Professor of Family
Medicine, University of South Florida College of Medicine, Tampa, and Medical Director, Carillon Executive Health Center
10 Years Younger, Trimmer, and Fitter Program, St. Petersburg, FL
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| Magnitude of problem: average person ≈10 yr older physiologically than 40 yr ago; children today at risk of having
shorter lifespans than their parents (accelerated aging syndrome); contributory factors include obesity, type 2 diabetes,
hypertension, and dyslipidemia
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| Normal aging: body fat increases by 1% and muscle mass decreases by 1% per year; ability to burn oxygen decreases ≈1%
per year; low-density lipoprotein (LDL) and total cholesterol increase by ≈1 mg/dL per year; speed of mental performance
declines
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| Seven accelerators of aging: all somewhat reversible
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 | Oxidative stress (rusting): slowed by — consuming “colorful plant foods” (eg, fruits, vegetables, grains; contain antioxidants
that slow free radical activity), engaging in aerobic activity (enhances and regenerates antioxidant enzyme systems);
possibly taking certain supplements
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| Low-carbohydrate diets: almost all antiaging nutrients come from carbohydrates; short-term side effects include constipation,
low energy, decreased sex drive, and halitosis; advise patients about untoward consequences, but also tell them
to avoid “bad carbs” (eg, white flour, corn syrup, sugar); long-term problems include increased risk for renal failure,
mental decline, and loss of bone density; comments—low carbohydrate diets associated with rapid weight loss due to
loss of fat and muscle mass; weight regained usually “all fat”; low-carbohydrate diet adversely affects metabolism and
may set up patients for metabolic syndrome
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| Metabolic syndrome: “hostile takeover of metabolism by fat cells”; fat cells—biochemically active and influence metabolism
by lowering temperature, lowering high-density lipoprotein (HDL), increasing appetite, and producing cytokines
that cause inflammation; can accelerate aging; diagnosis—requires ≥3 of 5 signs (eg, expanding waistline, increased
blood pressure [BP], elevated triglycerides, elevated fasting blood glucose [BG], decreased HDL); associated with increased
risks for clotting problems, inflammation, and cancer
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| Inactivity: average American not involved in enough physical activity to maintain appropriate metabolism, lipid profile,
BG levels, weight control, and cognitive function; fitness, strength, and endurance all plummeting; physical activity
best predictor of losing weight and keeping it off; adequate muscle mass—burns fat and calories; best predictor of surviving
pneumonia after 60 yr of age, avoiding nursing home admission due to fracture during 70s, living independently
into 80s and 90s; helps maintain healthy appearance
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| Unmanaged long-term stress: excessive stress adversely affects epinephrine and cortisol levels, thereby increasing BG
and cholesterol; injures memory center in brain, impairing cognitive function; shrinks muscle mass and bone
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| Toxins: corn syrup one of most common toxins (increases triglycerides); other toxins include hydrogenated fat, partially hydrogenated
fat, and mercury; foods helpful in removing toxins include garlic, onions, curry, and cruciferous vegetables
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| Inflammation: critical component of aging; Alzheimer’s disease inflammation of brain; inflammation also increased by
high BG levels, excessive intake of ω6 fatty acids, lack of ω3 fatty acids, and inactivity
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| Markers of physiologic age: body fat—weight one of worst measures; body mass index (BMI) much better; assessment of
muscle mass and waist/hip ratios best measures
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| Muscle mass: burns calories and helps maintain basal metabolic rate (BMR; adding 1 lb of muscle leads to 4-lb weight
loss in 1 yr); remarks—when patients diet, they consistently lose muscle mass, unless they add strength training
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| Aerobic fitness: elevated heart rate (HR) during exercise increases BMR; aerobic activity best predictor of keeping
weight off and enhances cognitive function; increased fitness level best predictor of avoiding cardiovascular events;
comments—BMR in people who do just moderate walk returns to normal within 1 hr; those who raise HR to 70% to
80% of maximal exertion burn more calories for 6 to 10 hr after exercise; mortality best predicted by fitness (measured
in METS [O2 consumption of 3.5 mL/kg per minute] achieved on treadmill test); HR recovery—at 1 min after peak
exertion, HR should drop ≥25 beats/min (bpm); drop <20 bpm concerning, and drop <12 bpm alarming
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| Cholesterol profile: generally rises ≈1 mg/dL per year; speaker’s favorite marker total cholesterol/HDL ratio (new normal
<3.5); optimal cholesterol level 100 plus age
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| Cognitive performance: mental speed, reaction time, and mental flexibility all decrease with age; memory loss less age-
dependent; goal to maximize mental performance and minimize loss; means for evaluating cognitive function include
Mini-Mental State Examination (30 questions; poor specificity) and Brain Symptom Score (preferred by speaker)
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| Questions on Brain Symptom Score: 1) losing things like keys, pens, glasses? 2) getting harder to find car in large parking
area? 3) having trouble remembering 7-digit telephone numbers long enough to dial? 4) need to write lists to remember
things? 5) forgetting names of movie and sports stars previously known very well? 6) easier to remember events from
20 yr ago than 2 days ago? 7) trouble balancing check book and figuring out server tips? 8) challenged when learning
new things? 9) does mind stay focused during lectures or wander more than in past? 10) harder to resume work on
project after being distracted?
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| Remarks: cognitive function testing indicated if patient, spouse, or other loved one expresses concern about memory,
mental speed, or cognitive function
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| Slowing aging process: possible by maintaining fitness, lean body mass, and strength; methods for checking fitness include
determining how many “push ups” people can do and assessing grip strength and mental performance; means for
decreasing physiologic age by 10 yr include decreasing body fat by 10%, increasing strength by 10%, lowering total cholesterol/HDL
ratio by 5%, and improving aerobic fitness by 10%; improve reaction time and cognitive flexibility
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| Speaker’s study: those in intervention group met weekly with trainer in gymnasium, heard weekly lectures by nutritionist,
underwent nutritional evaluation, and given 120 recipes for healthy meals; intervention group did much better physically
and cognitively than control group
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| Tools for empowering patients to slow aging process: nutrition—ask patients to add 16 “vitality foods” to diet (eg, green
leafy vegetables, lean protein from seafood and poultry, beans, soy products, whole grains, cruciferous vegetables, berries,
nuts, ground flax, garlic, herbs, green tea, nonfat yogurt with fruit, red wine [maximum of 2 glasses daily], dark
chocolate and cocoa [potent antioxidants; improve BP, decrease LDL oxidation]); foods must taste good; diet
principles—eat more fiber, fruits, and vegetables; avoid or limit saturated fat; avoid trans fats; eat foods with ω3 fatty
acids or take supplement; eat only whole grains; take supplements (eg, calcium 1000 mg daily plus magnesium); hydrate;
plan healthy desserts; watch portion size; choose healthy snacks; fiber—use combination of soluble and insoluble
fiber; 50% should come from fruits and vegetables; 30 g/day of fiber advised; fruits and vegetables—rich in fiber,
antioxidants, and fluid; help reduce weight; fat—sources of healthy fat include fish (eat 2 to 3 times/wk) and nuts; limit
saturated fat; avoid hydrogenated fat
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| Fitness: encourage regular aerobic workouts preceded by warm-up periods and followed by stretching; add strength training
2 to 3 times/wk to build lean body mass; aerobic component—attain 70% to 85% of maximum HR and maintain
for 30 min 5 to 6 days/wk; strengthening exercises—involve 8 to 10 body parts; stretching—do after workouts; prevents
injuries and improves performance
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| Comprehensive approach to promote success: relaxation; adequate sleep (≥7 hr daily); detoxification (limit exposure to
pesticides; eat only nonfat dairy products, lean meat and poultry; consume garlic, spices and cruciferous vegetables); skin
care (exercise, healthy foods, and topical vitamin A improve skin); supplements (should include multivitamin, B vitamins,
vitamin D, calcium, magnesium, selenium, and glucosamine); fish oil supplement (evidence-based; also obtained
from canned wild salmon or sardines)
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| RESTLESS LEGS SYNDROME —Max M. Bayard, III, Associate Professor of Family Medicine, East Tennessee State
University Quillen-Dishner College of Medicine, Johnson City, TN
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| Diagnostic criteria: 1) urge to move legs, usually with uncomfortable or unpleasant sensation; 2) symptoms usually exacerbate
during periods of rest or inactivity; 3) symptoms partially or totally relieved by movement; 4) symptoms worse or only
occur during evening or at night; supporting criteria (not required for diagnosis)—positive response to dopaminergic
treatment; presence of periodic limb movements of sleep; positive family history of restless legs syndrome (RLS);
comments—diagnosis often made on clinical grounds; avoid unnecessary testing
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| Impact of RLS: difficulty falling asleep or staying asleep (average <5 hr sleep nightly); impaired ability to perform daily
activities; cognitive deficits similar to those of sleep deprivation; anxiety and depression (severity correlates to severity
of RLS)
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| Prevalence: probably 8% to 10% of population; increases with advancing age; more common in women, overweight and
sedentary people, and in women who have had multiple births; ≈50% of patients have positive family history for RLS
(those who develop RLS at <45 yr of age more likely to have genetic component; autosomal dominant inheritance)
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| Key questions to ask suspected RLS patients: 1) have urge to move legs because of uncomfortable feeling? 2) is uncomfortable
feeling more predominant at rest? 3) is there at least temporary improvement with activity? 4) are symptoms
worse in evening or at night? if answer “yes” to all questions, patient probably has RLS
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| Secondary causes of RLS: iron deficiency (RLS may be due to low iron stores without anemia; associated with serum ferritin
levels <50 ng/dL; symptoms may resolve with iron supplementation); chronic renal failure (symptoms may resolve
after kidney transplantation); pregnancy (≈25% of pregnant women; severity and prevalence peak during third trimester;
may be associated with low prepregnancy iron and folate stores); spinal cord injury; peripheral neuropathy; some medications
(selective serotonin-reuptake inhibitors [SSRIs], antipsychotics, tricyclics, caffeine, lithium, metoclopramide);
comment—bupropion may improve symptoms
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| Pathophysiology: positron emission tomography (PET) and single photon emission computed tomography (SPECT) studies
show decreased dopamine binding in basal ganglia, compared to controls; serum iron stores correlate inversely with
severity of RLS
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| Clinical presentation: patients may complain of insomnia, leg pain, or “kicking all night”; look for “Bayard sign” (patient
looking at ceiling while describing pain)
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| Differential diagnosis: nocturnal leg cramps; peripheral vascular disease; neuropathies; akathisia
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| Clinical evaluation: history—ask about symptoms and chronic illnesses; get medication history and ask about blood loss;
determine severity of symptoms by using International Restless Legs Syndrome Study Group Severity Scale (10 questions;
self-administered; score of 0 to 4 for each question; patients with severe RLS have scores close to 40); physical
evaluation—do neurologic examination and check for peripheral vascular disease; laboratory studies—serum ferritin
and basic blood panel (complete blood count [CBC], serum urea nitrogen [BUN], serum creatinine, and BG)
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| Treatment: treat secondary causes—change medications; supplement iron; in patients with end-stage renal failure, kidney
transplant may resolve symptoms; completion of pregnancy may result in resolution of RLS; lifestyle changes—
decrease use of caffeine, tobacco, and alcohol; discontinue over-the-counter antihistamines; mild exercise or stretching
before sleep; weight reduction; medications—study by American Academy of Sleep Medicine concluded that dopamine
agonists first-line agents, followed by opioids, anticonvulsants, and benzodiazepines; drug therapy generally reserved
for patients with moderate-to-severe RLS (ie, symptoms at least 15 nights/mo); ropinirole only drug approved
in United States for treating moderate-to-severe RLS; other drugs used off-label
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| Dopamine agonists: work by stimulating dopamine receptors; include ropinirole, pramipexole, cabergoline, and pergolide;
side effects include nausea, daytime somnolence, and orthostasis
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| Dopaminergic agents: include levodopa and carbidopa; big problem augmentation (symptoms occur earlier in day and
more severe and widespread than before treatment); rebound (symptoms occur at end of dosing period)
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| Comments: pramipexole nonergot-derived dopamine agonist; pergolide ergot-derived dopamine agonist; gabapentin
about as effective as ropinirole in studies; in study, oxycodone associated with decreased leg symptoms and improved
daytime alertness
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| Starting doses: ropinirole 0.25 mg (maximum dose ≈4 mg); pramipexole 0.125 mg (maximum dose 1.5 mg); pergolide
0.05 mg (maximum dose unknown; studies go to 0.7 mg)
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| Choice of drug: dopamine agonists first-line agents, followed by gabapentin; opioids used in patients with coexisting
pain; levodopa used in patients with intermittent symptoms; benzodiazepines helpful when loss of sleep major concern
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Educational Objectives
| The goal of this program is to educate the listener about improving health and longevity through diet and exercise and about
the restless legs syndrome. After hearing and assimilating this program, the clinician will be better able to:
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| 1. List the 7 accelerators of aging (eg, oxidative stress, low-carbohydrate diet, metabolic syndrome, inactivity, unmanaged
stress, toxins, inflammation).
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| 2. Assess body composition, including body fat and muscle mass.
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| 3. Recommend an exercise and diet program to enhance the physical health and cognitive function of patients and to
increase longevity.
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| 4. Diagnose patients with the restless legs syndrome (RLS).
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| 5. Prescribe medications to treat patients with moderate-to-severe RLS.
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Discussed on This Program
Bupropion HCl [Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban] Calcium (several preparations and trade names)
Gabapentin [Neurontin]Levodopa and carbidopa [Parcopa, Sinemet-10/100, Sinemet-25/100, Sinemet-25/250, Sinemet
CR]
Lithium [Eskalith, Eskalith CR, Lithobid, Lithonate, Lithotabs]
Metoclopramide [Maxolon, Metoclopramide Intensol, Octamide PFS, Reclamide, Reglan]
Oxycodone HCl (several trade names)
Pergolide mesylate [Permax]
Pramipexole [Mirapex]
Ropinirole HCl [Requip]
Suggested Reading
Ball GD et al: Physical activity, aerobic fitness, self-perception, and dietary intake in at-risk overweight and normal weight
children. Can J Diet Prac Res 66:162, 2005; Burke LM, Kiens B: “Fat adaption” for athletic performance: the nail in the
coffin? J Appl Physiol 100:7, 2006; Chauhan R et al: Health benefits of physical activity. CMAJ 26:776, 2006; Clark
MM: Restless legs syndrome. J Am Board Fam Pract 14:368, 2001; Despres JP: Our passive lifestyle, our toxic diet, and
the atherogenic/diabetogenic metabolic syndrome: can we afford to be sedentary and unfit. Circulation 112:453, 2005;
Elmer PJ et al: Effects of comprehensive lifestyle modification on diet, weight, physical fitness, and blood pressure control:
18-month results of a randomized trial. Ann Intern Med 144:485, 2006; Esposito K, Giugliano D: Obesity, the metabolic
syndrome, and sexual dysfunction. Int J Impot Res 17:392, 2005; Friedlander AH et al: Restless legs syndrome:
manifestations, treatment, and dental implications. J Am Dent Assoc 137:755, 2006; Garcia MC: Inflammatory, autoimmune,
chronic diseases: bad diet and physical inactivity are causes or effects? Med Hypotheses 66:939, 2006; Grant RW,
Meigs JB: Management of the metabolic syndrome. Panminerva Med 47:219, 2005; Irazusta A et al: Exercise, physical
fitness, and dietary habits of first-year female nursing students. Biol Res Nurs 7:175, 2006; Janzen L et al: An overview of
levodopa in the management of restless legs syndrome in a dialysis population: pharmakinetics, clinical trials, and complications
of therapy. Ann Pharmacother 33:86, 1999; Leyk D et al: Physical performance, body weight, and BMI in young
adults in Germany. Int J Sports Med 27:642, 2006; Masley SC: Ten Years Younger. New York City, Broadway Books,
2005; Molnar MZ et al: Ropinirole treatment for restless legs syndrome. Drugs Today 42:587, 2006; Naghii RR: The importance
of body weight and weight management for military personnel. Mil Med 171:550, 2006; Pate RR et al: Promoting
physical activity in children and young: a leadership role for schools. A scientific statement from the American Heart Association
Council on Nutrition, Physical Activity, and Metabolism (Physical Activity Committee) in collaboration with the
Councils on Cardiovascular Disease in the Young and Cardiovascular Nursing. Circulation 114:1214, 2006; Paulus W,
Trenkwalder C: Less is more: pathophysiology of dopaminergic-therapy-related augmentation in restless legs syndrome.
Lancet Neurol 5:878, 2006; Shilts MK et al: Goal setting as a strategy for dietary and physical activity behavior change: a
review of the literature. Am J Health Promot 19:81, 2004; Thorpy MJ: New paradigms in the treatment of restless legs
syndrome. Neurology 64(12 Suppl 3):S28, 2005; Wahlqvist ML et al: Age-fitness: How achievable with food? Forum
Nutr 56:258, 2003; Weil RM: Lowering your risk of cardiovascular disease. Diabetes Self Manag 19:28, 2002.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. The following has been disclosed:
Dr. Masley is the author of a book entitled, “Ten Years Younger.”
Dr. Bayard was recorded September 30, 2006, and Dr. Masley, October 1, 2006, at the Annual Scientific Assembly of the
American Academy of Family Physicians, held in Washington, DC. The Audio-Digest Foundation thanks the speakers and
the Academy for making this program possible.
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