1. REGIONAL SYMPOSIUM ON ALZHEIMERS DISEASE AND RELATED DISORDERS IN THE MIDDLE EAST Istanbul, Turkey October 1-2, 2005 Convener: Robert P. Friedland, MD LOC Chair: Murat Emre, MD w w w. w o r l d e v e n t s f o r u m. c o m / a l z. h t m

2. Gene environment interactions in Alzheimers Disease Robert P. Friedland, Lindsay A. Farrer, Rivka Inzelberg, Amin Abuful, Magda Marsarwa, Rosa Strugatsky, Clinton Baldwin, Grace Petot Cleveland, Ohio, USA; Boston, Massachussetts USA; Hadera, Israel

3. CWRU Lab.Neurogeriatrics S. Debanne, PhD R. Friedland, MD T. Fritsch, PhD E. Grady, BA K. Gustaw, MD, PhD S. Humphrey, BA A. Lerner, MD G. Petot, MS CWRU Dept. Pathology G. Perry, PhD M. Smith, PhD Boston Univ. C. Baldwin, PhD L. Farrer, PhD Sun Health Res. Inst. L. Sparks, PhD Cleveland Clinic D.Jacobsen,PhD Hillel Yaffe Med. Center/Technion A. Abuful, RN R. Inzelberg, MD M. Masarwa, MD R. Stugatsky Hadassah Hosp Hebrew Univ, Jerusalem I. Biran, MD J. Kark, MD, PhD Y. Newman, PhD State University of New York, Stony Brook D. Goldgaber, PhD

4. Interactions in Alzheimers disease Whats going wrong in the AD brain? Genes Environment Africans, African Americans Caucasians Middle East Implications for health and public policy

5. Amyloid and aging vessels All people over 60 have aortic amyloid Medin: an integral fragment of aortic smooth muscle cell-produced lactadherin Also found in temporal arteries Comes from smooth muscle cells Haggqvist et al, 1999; Peng et al, 2002 Amyloid deposited on internal elastic lamina in a temporal artery without inflammation.

6. Helmuth, 2002 secretase----

8. Alzheimer physiology – choose your poison! 1. APP expression 2. APP cleavage 3. ABeta aggregation and toxicity 4. ABeta clearance from brain to blood 5. ABeta clearance from blood

11. Why is this important?

12. Age and Alzheimers disease The risk of getting the disease doubles every 5 years after the age of 65 The most important risk factor for AD is age

13. The second most important risk factor for AD is genetics Autosomal dominant chromosome 21 APP chromosome 14 Presenilin 1 chromosome 1 Presenilin 2 ~ total > 160 rare but highly penetrant mutations~ Co-dominant chromosome 19 Apolipoprotein E Recessive none ?????????????????????????

14. What determines the function of a gene? 1.Nucleotide sequence 2.DNA repair 3.Expression accuracy 4.Expression levels 5.Interaction of gene products and environmental factors

15. What determines the function of a gene? 1.Nucleotide sequence 2.DNA repair 3.Expression accuracy 4.Expression levels – influenced by both genes and environment! 5.Interaction of gene products and environmental factors

17. TTR binds best to AB 42 (Tsuzuki et al 2000)

18. TTR and Alzheimers disease MIRAGE database (L. Farrer, PI) 256 Caucasian AD cases, 306 non-demented sibs, 227 African American AD cases, 165 non-demented sibs. 119 (Caucasian) and 79 (African American) AD cases and non-demented spouses. SNP associations were evaluated using family- based association tests, generalized estimating equations and chi square tests of proportion. No relationships between disease and 3 TTR polymorphisms were uncovered thus far. Farrer et al (preliminary data - unpublished) 27424463intron rs723744 27425782intron rs1080094 27428958intron rs3794884 Chromosome 18

19. TTR and AD TTR levels decreased in plasma and CSF in AD patients, cor. with dementia severity Riiosen et al, 1988; Davidsson et al,1997; Serot et al,1997; Merched et al, 1998, Riisoen,1988 In early life AD Tg mice have increased TTR expression (before ABeta deposition and neuronal loss)….also neutralization of TTR enhances AD pathology in AD Tg mice Stein and Johnson, 2002; Stein et al, 2004

20. Worldwide distribution of AD Age-related Less in Asia, Africa, India More in African-Americans and Hispanics than Caucasians or Africans Few studies in the Middle East

21. Wadı Ara studıes Rıvka Inzelberg, Co-Prıncıpal Investıgator Populatıon based survey of genetıc and envıronmental factors Genes: inbreedıng, populatıon bottle- neck Envıronment: educatıon, smokıng, diet, actıvıtıes, alcohol, hypertensıon

22. Every hereditary monarch in Europe at the beginning of the 20th century was a descendent of Edward III (Manrubia et al, 2003) Edward III, 1312-1377

23. Alzheimers disease in Wadi Ara familial clustering of AD [with low Apo E e4 allele frequency, ~4%], perhaps related in inbreeding genetic linkages of AD to sites on chromosomes 9, 10 and 12. Environmental factors may include low levels of education and fish consumption, smoking, high fat diet, hypertension and physical inactivity.

24. Alzheimers disease in Africans and African Americans Higher e4 freq. in Africans and African - Americans Lower AD prevalence and incidence in Africans and higher in African- Americans (compared to Caucasians) (Hendrie et al, 1999, Kalaria et al, 1999, Evans et al, 2000)

25. Obesity and Alzheimers disease 96 cases, 275 Controls; adjusted for year of birth, Apo E genotype, gender and education. [Petot et al, unpublished]

26. Dietary fat and AD High fat diets during the 40-59 year age period were not a risk factor for AD, regardless of ApoE status, and they may be protective. ApoE e4 risk for AD increased 2.7 times with high linoleic acid diets during the 40-59 year age period. 117 Cases 356 controls, adjusting for year of birth, Apo E genotype, gender and education Petot et al, (ANA, Sept. 2005)

27. Fish, PUFA and AD Fish consumption is linked to lower AD risk (also CAD, stroke, cancer) (Kalmijn et al, 2000; Morris et al, 2003, Friedland, 2003) Dietary intake of omega 3 PUFAs influences the expression levels of many genes controlling resistance to endogenous free radicals and ABeta protein balance

28. Gene expression changes induced by PUFAs increaseddecreased * TTRlipogenesis antioxidantsROS gelsolinCOX2 anti-inflamm. iNOS pro-apoptotic casp. *Short-term administration of omega 3 fatty acids from fish oil increased TTR transcription 10X in aged rat hippocampus Puskas LG et al, 2003 Akba et al, 2002,Takahashi et al, 2003, Lapillonne et al, 2004

29. Proposal: -Brain disease with aging are due to the failure of protective mechanisms resulting from gene-environment interactions, including environmental effects on gene expression

30. Potentially modifiable protective factors for AD high education and occupational achievement vigorous participation in mental and physical activities no cardiac disease, diabetes, hypertension

31. Protective Factors for Alzheimers disease (cont). dietary use of antioxidants low level of alcohol consumption avoidance of obesity, high fat diet and head injury

32. Implications for public policy Lıfelong educatıon and opportunıtıes for mental and physıcal actıvıtıes Access to care Research fundıng

33. ACKNOWLEDGEMENTS National Institute on Aging Joseph and Florence Mandel Research Fund Nickman Family Philip Morris, USA Fullerton Family GOJO Corp. Pfizer, Inc. Institute for the Study of Aging Peter B. Lewis Building, CWRU

35. Nutritional properties of Meat FatCommercial Fat Africa (g/100g)Meat (g/100g) Wildebeast4.9 Lamb21.6 Waterbuck1.8 Pork22.6 Cape buffalo6.3 Choice beef23.8 Eland4.8 Extra lean ground beef17.1 (adapted from Eaton, 1992)

36. Enhanced longevity In Western Europe… from 1950 to 2000 the probability of surviving from age 80 to 100 increased 20-fold. (Vaupel et al, Science, 2003)

39. EURODEM prevalence rates Age group Male Female 30-59 0.2% 0.1% 60-64 1.6% 0.5% 65-69 2.2% 1.1% 70-74 4.6% 3.9% 75-79 5.0% 6.7% 80-84 12.1% 13.5% 85-89 18.5% 22.8% 90-94 32.1% 32.3% 95-99 31.6% 36.0%

40. O 2 Radical Absorbance Capacity Fresh Fruit Veggies and Legumes Blueberries 2,400 Kale 1,770 Blackberries 2,036 Spinach 1,260 Cranberries 1,750 Brussel sp. 980 Strawberries 1,540 Alfalfa sp. 930 Raspberries 1,220 Broccoli 890 Plums 949 Beets 840 Avocado 782 Red Bell P. 460 Oranges 750 Kidney B. 460 Red Grapes 739 Onions 450 Cherries 670 Corn 402

41. Aging and dementia in the Middle East 22 countries Over 300 million people

42. MMWR Weekly, Volume 54, No. 8, March 4, 2005

43. Obesity and Apo E genotype

46. Other influences on TTR TTR is also increased by Ginkgo biloba, nicotine, some NSAIDs TTR may be decreased by insulin and inflammation Watanabe et al, 2001, Li et al, 2000

47. Alzheimers disease and diet Lipids (saturated fat and PUFAs) Fish Homocysteine/methionine & vitamins (folic acid, B12, B6) (Kalmijn, et al 1997, 2000; Morris et al, 2003; Clarke et al, 1999; Friedland, 2003)

48. Homocysteine and TTR TTR may bind to homocysteine (homocysteinylation, disulfide bonds to cysteine), possibly interfering with TTRs ability to bind ABeta Lim et al, 2003

49. Aging is inevitable? NO! It is an opportunity

50. Statins and AD Statins may lower AD risk (Jick et al, 2001, Wolozin et al, 2001) Statins are anti-inflamatory as well as HMG- Co A reductase inhibitors (Hernadez-Presa et al, 2002) Plasma lipid levels may influence balance of secretases (Beyreuther et al, 2001)

51. Factors influencing Abeta clearance from brain to blood Enhance ? Anti-A Abs TTR Apo E 2-3 Apo J Gelsolin GM1 (Goldgaber et al, 1995; Matsuoka et al, 2003) Diminish ? Apo E 4 High fat diet High plasma lipid levels Insulin Apo e4 has less affinity for Abeta (Pillot et al, 1999) Insulin decreases Abeta elimination (Shiiki et al, 2004)

52. The major lipid binding domain of apo E is also the C-terminal domain that binds ABeta (aa 244-271) (Pillot et al, 1999, Huang et al, 2004)

53. Peripheral anti-A antibody alters CNS and plasma A clearance and decreases brain A burden in a mouse model of Alzheimer s disease R.B. DeMattos, K.R. Bales, D. J.Cummins, J-C. Dodart, S.M. Paul, D.M. Holtzman PNAS 98:8850, 2001 Peripheral sink hypothesis

54. Alzheimer physiology – choose your poison! 1. APP expression 2. APP cleavage 3. ABeta aggregation and toxicity 4. ABeta clearance from brain to blood 5. ABeta clearance from blood

55. Alzheimer physiology – choose your poison! 1. APP expression 2. APP cleavage 3. ABeta aggregation and toxicity 4. ABeta clearance from brain to blood 5. ABeta clearance from blood

57. Even an ordinary globular protein can assume an amyloid configuration (EM of fibrils formed from horse skeletal-muscle myoglobin after haem extraction and staining with uranyl acetate) Nature, 2001