C A R D I O VA S C U L A R A G E I N G

ReViews
Interventions to promote
cardiometabolic health and slow
cardiovascular ageing
Luigi Fontana1,2
Abstract | Cardiovascular ageing and the atherosclerotic process begin very early in life, most
likely in utero. They progress over decades of exposure to suboptimal or abnormal metabolic and
hormonal risk factors, eventually culminating in very common, costly , and mostly preventable
target-​organ pathologies, including coronary heart disease, stroke, heart failure, aortic aneurysm,
peripheral artery disease, and vascular dementia. In this Review , we discuss findings from
preclinical and clinical studies showing that calorie restriction (CR), intermittent fasting, and
adjusted diurnal rhythm of feeding, with adequate intake of specific macronutrients and
micronutrients, are powerful interventions not only for the prevention of cardiovascular disease
but also for slowing the accumulation of molecular damage leading to cardiometabolic
dysfunction. Furthermore, we discuss the mechanisms through which a number of other
nondietary interventions, such as regular physical activity , mindfulness-​based stress-​reduction
exercises, and some CR-​mimetic drugs that target pro-​ageing pathways, can potentiate the
beneficial effects of a healthy diet in promoting cardiometabolic health.

1
Division of Geriatrics and
Nutritional Science,
Washington University,
St. Louis, MO, USA.
2
Department of Clinical and
Experimental Sciences,
Brescia University Medical
School, Brescia, Italy.
e-​mail: lfontana@
wustl.edu
https://doi.org/10.1038/
s41569-018-0026-8
Cardiovascular ageing is a biological phenomenon
caused by the accumulation of cellular, tissue, and organ
damage with time leading to a progressive decline in
function and structure. Some build-​up of molecular
damage with advancing age is inevitable. For example,
our arteries and heart become stiffer and more fibrotic,
and our maximal heart rate declines linearly as we grow
older. However, ageing does not itself cause cardiovas-
cular disease (CVD). Instead, a persistent exposure to
unhealthy lifestyles (including excessive calorie intake,
poor nutrition, sedentary lifestyle, psychological stress,
and smoking) accelerates cardiovascular functional deteri­
oration and drastically increases the risk of developing
one or more of the following conditions: coronary heart
disease, stroke, heart failure, aortic aneurysm, periph-
eral artery disease, vascular dementia, chronic nephro­
pathies, nonalcoholic fatty liver disease, and some of the
most common types of cancer. For example, excessive
energy intake and central adiposity cause insulin resist-
ance, type 2 diabetes mellitus (T2DM), inflammation,
dyslipidaemia, elevated blood pressure, oxidative stress,
and many other metabolic and hormonal alterations
that trigger a number of detrimental molecular and
cellular adaptations leading to functional and structural
CVDs1 (Fig. 1).
This Review discusses findings from experimental and
human studies indicating that calorie restriction (CR) with
adequate nutrition is a powerful intervention not only for
the prevention of CVD but also for slowing the accumu-
lation of molecular damage leading to accelerated ageing.
Data indicate that both intermittent fasting and adjusted
diurnal rhythm of feeding, lowered intake of protein and
specific amino acids, and the nutritional modulation of
the microbiome can also be important2. Furthermore,
we discuss a number of other nondietary interventions,
such as regular physical activity, mindfulness-​based stress-​
reduction exercises, and some CR-​mimetic drugs, that
have been shown to have a role in preventing CVD.
Nutritional modulation
Calorie restriction. CR without malnutrition is the most
powerful intervention for slowing ageing and for pre-
venting multiple age-​associated chronic diseases, includ-
ing cardiomyopathy, nephropathy, neurodegeneration,
cancer, and autoimmune diseases in rodents and other
model organisms3,4. In particular, CR has a striking effect
in preventing the typical and dramatic accumulation of
cardiomyopathic degenerative fibrotic and thrombotic
lesions that occurs in ad libitum-​fed rodents with time5.
Although nearly all mouse strains are resistant to athero­
sclerosis even when fed an atherogenic diet, data from
genetic murine models of atherosclerosis (such as Apoe−/−
mice and Ldlr−/− mice) indicate that animals placed on a
40% CR diet have 33–75% smaller athero­sclerotic lesions

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Key points inhibition of nutrient-​sensing pathways (such as the

insulin–insulin-​like growth factor (IGF)–mechanistic
• Cardiovascular ageing is a biological phenomenon caused by the accumulation over target of rapamycin (mTOR) pathway), leading to
time of damage at the cellular, tissue, and organismal level leading to a progressive increased autophagy and proteostasis, and reduced
decline in function and structure. accumulation of cellular ‘garbage’, such as amyloid, and
• Unhealthy lifestyle practices (such as poor nutrition, sedentary lifestyle, mental stress, proteins that interfere with normal cell function3,24,25;
smoking, and pollution) drastically increase the accrual of cellular and tissue damage, and reprogramming of gut microbial biology and meta­
leading to cardiovascular disease.
bolic functions26. Figure 3 summarizes some of the
• Calorie restriction, intermittent fasting, and adjusted diurnal rhythm of feeding major metabolic and molecular pathways that are trig-
are powerful interventions for the prevention of cardiovascular dysfunction and
gered by CR and other interventions, which might have
cardiovascular disease.
important roles in enhancing endothelial function and
• Lowered intake of protein, specific amino acids, and saturated fatty acids (typical of
cardioprotection, and in reducing immune activation
the Mediterranean diet) and nutritional modulation of the gut microbiome can have
additional cardioprotective roles.
and smooth muscle cell and cardiac hypertrophy.
• Regular endurance and resistance exercise, mindfulness-​based stress reduction
programmes, and some calorie-​restriction mimetic medications can potentiate the
Intermittent fasting and meal timing. Accumulating
beneficial effects of a healthy diet. data suggest that meal timing and diet quality both have
central roles in promoting cardiometabolic health2. As
with chronic CR, both intermittent fasting and time-​
than ad libitum-​fed mice6. Moreover, resistance to myo- restricted feeding extend lifespan by up to 30% in mice,
cardial infarction and post-​ischaemic recovery is sub- independent of calorie intake27. Both intermittent fasting
stantially better in CR than in ad libitum-​fed mice7. Data and time-​restricted feeding (such as feeding of mice dur-
from randomized clinical trials (RCTs) of 30% CR in ing 8 h of the dark phase of the daily cycle) protect mice
Rhesus monkeys show a 50% reduction in cardiovascu- against obesity, hypertension, glucose intolerance, insu-
lar and cancer morbidity and mortality, and a dramatic lin resistance and diabetes, inflammation, and the clini-
reduction in several cardiometabolic risk factors8. In the cal progression of CVD28. Multiple mechanisms mediate
University of Wisconsin primate study9,10, CR has also these beneficial effects of fasting, including improved
been shown to slow age-​related hearing loss, brain atro- insulin sensitivity, increased levels of fibroblast growth
phy, and sarcopenia. Indeed, in contrast to the current factor 21, reduced inflammation and oxidative stress,
belief that chronic CR causes muscle atrophy and frailty, and enhanced cellular and molecular adaptive stress
a 2018 analysis indicates that weakness, slowness, poor responses, including improved mitochondrial function,
endurance, and total incidence of frailty were markedly enhanced proteostasis via chaperones such as heat shock
lower in the CR monkeys than in ad libitum-​fed con- protein 70 and endoplasmic reticulum chaperone BiP,
trol monkeys11. In humans, data from observational and and increased autophagy and endogenous antioxidant
randomized clinical studies show striking CR-​mediated enzymatic systems via inhibition of the RACα serine/
cardiometabolic adaptations that resemble those of threonine-​protein kinase (AKT1)–mTOR pathway27,28.
long-​lived CR rodents12. In particular, long-​term CR For example, treatment of mice with β-​hydroxybutyric
without malnutrition in humans results in profound acid, an endogenous histone deacetylase (HDAC) inhib-
and sustained beneficial effects on the major CVD risk itor, induced by fasting, protects against oxidative stress,
factors: serum levels of LDL cholesterol, HDL choles- NLRP3 (NOD-, LRR- and pyrin domain-​containing 3)
terol, triglycerides, glucose, C-​reactive protein, and inflammasome-​mediated inflammation, and ischaemic
blood pressure, which usually increase with advancing brain damage via activation of the hydroxycarboxylic
age13–15. Moreover, as in CR rodents, individuals practis- acid receptor 2 on infiltrating macrophages29–31. Data
ing long-​term CR have significantly lower intima–media from short-​term RCTs indicate that alternate-​day fasting,
thickness of the common carotid arteries, improved left or fasting for two nonconsecutive days per week, signifi-
ventricular diastolic function (lower chamber stiffness cantly reduces body mass; fat mass; waist circumference;
and augmented viscoelasticity), and improved heart-​rate serum concentrations of LDL cholesterol, triglycerides,
variability, strongly suggesting that CR retards the age-​ and C-​reactive protein; and level of arterial blood pres-
associated deterioration of cardiovascular function in sure32,33. Data also suggest that alterations of eating pat-
humans as well as in other animals13,16–18 (Fig. 2). terns over the day have substantial effects in modulating
The precise biological and cellular mechanisms cardiometabolic health in humans, probably because of
responsible for the beneficial effects of CR on cardio- modifications of a number of energy-​sensing pathways
vascular health are not known but are likely to involve (such as 5′-AMP-​activated protein kinase (AMPK),
a constellation of factors, including prevention of dys- AKT1–mTOR, and cAMP-​responsive element-​binding
lipidaemia, chronic inflammation, and immune acti- protein (CREB)) that are involved in cellular metabolism
vation caused by increased adipokine and cytokine and rhythmic oscillations of circadian clock targets2,28.
production13–16,19; improved insulin sensitivity with Mice with an S714G mutation in the circadian clock gene
reduced activation of receptors for advanced glycation Per1 rapidly develop obesity on a high-​fat diet because
end products15,20,21; reduced oxidative-​stress-induced the disrupted circadian clock alters the expression of
lipid, protein, and DNA damage resulting in optimal several important metabolic regulators in the liver and
endothelial function 22,23; reduction of sympathetic adipose tissue34. Interestingly, women with obesity
nervous and angiotensin system activation as well as and polycystic ovary syndrome who ate most of their
alterations in multiple neuroendocrine systems5,18,21; daily calories at breakfast and lunch (980 kcal breakfast,

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Mental stress Sedentary lifestyle Excessive calorie intake Unhealthy diet unhealthy Western diet42. In RCTs of individuals who are
overweight or obese, a high-​protein diet, which involved
increased consumption of dairy and meat products and
↑ Sympathetic and Abdominal obesity Dyslipidaemia whey protein supplementation for 6–18 weeks, decreased
adrenal activity
Hypertension insulin sensitivity43,44. Moreover, another trial indi-
Oxidative stress cated that adding whey protein to the low-​calorie diet
Insulin resistance Inflammation Diabetes mellitus Chronic nephropathy
(to increase protein intake from 0.8 g/kg per day to 1.3 g/kg
per day) of postmenopausal women with obesity com-
Coronary heart disease
pletely prevented the beneficial effect of 10% weight loss
Hyperinsulinaemia Smoking on insulin-​mediated glucose disposal, measured using
↓ SHBG and IGFBP1 Stroke
the hyperinsulinaemic–euglycaemic clamp procedure45.
Excessive consumption of food of animal origin can
Dementia affect cardiovascular health in several other ways. For
example, many epidemiological studies have shown that
Cancer NAFLD limiting the intake of saturated fatty acids from animal
foods is associated with lower serum LDL-​cholesterol
Fig. 1 | Unhealthy lifestyles and disease risk. Unhealthy lifestyle effectors, including
concentration and lower incidence of coronary heart
excessive calorie intake, unhealthy diet, sedentary lifestyle, mental stress, and smoking,
disease. Replacing 5% of energy intake from saturated
modulate important metabolic and hormonal factors associated with the development
of the most common age-​associated chronic diseases. IGFBP1, insulin-​like growth fat with an equivalent quantity of energy from poly­
factor-​binding protein 1; NAFLD, nonalcoholic fatty liver disease; SHBG, sex unsaturated fats, monounsaturated fats, or carbohydrates
hormone-​binding globulin. from whole grains is estimated to be associated with
a 25%, 15%, and 9% reduced risk of coronary heart
disease, respectively46. By contrast, substituting refined
640 kcal lunch, and 190 kcal dinner) experienced more carbohydrates for saturated fats is linked to an increased
weight loss and higher glucose tolerance and insulin risk of CVD46. Data from several RCTs have shown that
sensitivity than control women randomly assigned to an substituting vegetable polyunsaturated fat for saturated
isocaloric diet with a later meal pattern (190 kcal break- fat decreases CVD by roughly 30%47. Nutritional modu­
fast, 640 kcal lunch, and 980 kcal dinner)35. However, lation of gut microbiome structure and function also
although preliminary findings from these interven- seems to have a role in shaping metabolic and cardiovas-
tions are promising, further well-​conducted RCTs are cular health48,49. For example, trimethylamine-​N-oxide,
warranted to understand their real clinical applicability. a gut bacteria derivative metabolite of l-​carnitine and cho-
line, which are abundant in red meat, eggs, and cheese,
Macronutrient composition and diet quality . Dietary increases platelet aggregation, vascular inflammation,
composition, and in particular protein and fat intake endothelial dysfunction, and cardiovascular mortality50.
from animal sources, can also affect metabolic health and The consumption of a variety of foods rich in fibre,
the risk of developing CVD. In contrast to the widespread vitamins, and phytochemicals, which is typical of the tra-
and unsupported belief that high-​protein diets combat ditional Mediterranean diet, can exert additional cardio-
obesity and its associated health conditions, accumulat- metabolic benefits51–53. For example, nutrients contained
ing evidence points instead to a restriction of protein or in nuts and seeds, such as ω6 and ω3 polyunsaturated
specific amino acids in the diet as an important factor fatty acids and plant sterols, might have a substantial role
in increasing health span and metabolic health2,36. In in lowering LDL-​cholesterol level. Data from multiple
mice, both methionine restriction and a reduction of the epidemiological studies suggest that consuming five serv-
protein:carbohydrate ratio increase health and lifespan ings of nuts per week is linked with a 40–60% decrease in
by up to 30%37,38. Methionine restriction, even when major CVD events, and in a clinical trial, consuming a
implemented in mice aged 12 months, causes a decrease range of cholesterol-​lowering foods (such as nuts, plant
in visceral fat and improves glucose tolerance and insu- sterol ester, soy protein, and viscous fibres from grains and
lin sensitivity in both lean and diet-​induced obese mice psyllium) caused a significant 13% reduction in serum
by increasing hepatic expression levels of the insulin-​ LDL-​cholesterol level54,55. Indeed, phytosterols and water-​
sensitizing hormone fibroblast growth factor 21 and soluble fibre, which can be found in high concentrations
reducing hepatic lipogenic gene expression37,39. in beans, whole grains, nuts, and fruits, can limit the
Data indicate that selective reduction of branched-​ (re) absorption of bile acids and cholesterol in the small
chain amino acids (BCAAs) has a crucial role in regu- intestine and consequently increase the liver uptake of
lating insulin sensitivity as well. The circulating levels of LDL56,57. The traditional Mediterranean diet, which is
BCAAs are higher in insulin-​resistant humans and in characterized by a low consumption of animal products
several rodent models of diet-​induced obesity, and and high intake of vegetables, minimally processed grains,
BCAA supplementation impairs insulin sensitivity40. beans, nuts, seeds, fruits, and extra-​virgin olive oil, and a
By contrast, restriction of dietary BCAAs is as effective moderate intake of red wine, is very high in antioxidant and
as reduction of dietary protein in improving glucose tol- anti-​inflammatory compounds, such as vitamin E, vitamin
erance, alleviating β-​cell metabolic stress, and reducing C, β-​carotene, selenium, and flavonoid phytochemicals51.
adiposity in both mice and humans41. Indeed, selective In the PREDIMED primary prevention RCT58,59, individ-
restriction of the BCAAs can completely restore meta- uals at high cardiometabolic risk randomly assigned to a
bolic health in diet-​induced obese mice consuming an Mediterranean diet, supplemented with extra-​virgin olive

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Calorie restriction

Metabolic adaptations

Lipid profile Inflammation Glucose metabolism Endocrine profile Redox status

↓ LDL cholesterol ↓ White blood cells ↓ Glucose levels ↓ Leptin ↓ F2-isoprostanes
↑ HDL cholesterol ↓ C-reactive protein ↓ Insulin levels ↑ Adiponectin ↓ White blood cell
↓ Triglycerides ↓ Cytokine levels ↑ Insulin sensitivity ↓ T3, ↑ IGFBP1, and ↑ SHBG DNA oxidation
↓ Adhesion molecules ↓ Angiotensin I ↓ DNA fragmentation

Physiological adaptations

Improved endothelial Low blood pressure Improved heart rate Low intima–media Improved left ventricular
function variability thickness diastolic function

Clinical outcomes

↓ Risk of coronary heart disease ↓ Risk of stroke ↓ Cardiac arrhythmias ↓ Peripheral artery disease ↓ Heart disease

Fig. 2 | Effects of calorie restriction. Schematic model of the metabolic and physiological adaptations to chronic calorie
restriction in humans that contribute to the prevention of multiple cardiovascular diseases. IGFBP1, insulin-​like growth
factor-​binding protein 1; SHBG, sex hormone-​binding globulin; T3, triiodothyronine.

oil or nuts, had a significant reduction in circulating levels
of oxidized LDL and inflammatory markers and, over a
median follow-​up of 4.8 years, had an approximately 30%
reduction in incidence of major cardiovascular events.
Other compounds found in fish and extra-​virgin olive
oil, such as ω3 fatty acids and oleocanthal, might exert
additional anti-​inflammatory and platelet antiaggregant
activities by inhibiting the NLRP3 inflammasome and
cyclooxygenase activity, respectively60,61.
Exercise-​induced modulation
Physical exercise is essential for cardiovascular health
because mammalian evolution occurred in the con-
text of vigorous physical activity. Selective pressures
dictated by the hunter–gatherer lifestyle shaped the
human genome over ~2 million years. Not surprisingly,
numerous epidemiological studies have shown that
reduced physical activity and low aerobic capacity are
strong and independent predictors of CVD mortality,
although higher levels of physical exercise do not elim-
inate the higher risk of death associated with excessive
adiposity62,63. For example, in women, brisk walking for
30 min daily (5 days per week) lowers the risk of devel-
oping CVD by 30% and reduces the use of medications
for hypertension, T2DM, and hypercholesterolaemia64,65.
Moreover, data from a meta-​analysis support a role of
extended sedentary time in increasing risk of develop-
ing and dying from CVD, independent of the number of
exercise sessions per week66.
Aerobic endurance exercise . Experimental data show
that regular endurance exercise has a powerful effect on
improving metabolic and cardiovascular health, even if
it seems not to slow ageing per se. Indeed, in a number of
experiments conducted by Holloszy and colleagues, exer-
cise in the form of voluntary wheel running increased
average lifespan but did not increase maximal lifespan
despite decreasing availability of energy for growth, cell
proliferation, and other processes and despite having a
greater protective effect against body fat accumulation
and development of insulin resistance with advancing
age than CR that caused a similar decrease in availabil-
ity of energy67 (Fig. 4). Multiple mechanisms mediate the
beneficial effects of endurance exercise on cardiometa-
bolic health, including a protective effect against abdom-
inal obesity by increasing mitochondrial biogenesis and
the consumption of oxygen and calories14,68,69; increase
in muscle insulin sensitivity and insulin responsive-
ness as a consequence of increased expression of the
insulin responsive glucose transporter type 4 (GLUT4;
also known as SLC2A4) and in glycogen synthase
activity14,69–71; improved glucose tolerance despite lower
insulin levels because of the augmented insulin sensi-
tivity of the active muscles and increased adiponectin
induced by visceral fat loss14,70,71; elevated expression of
lipoprotein lipase in skeletal muscle, with a reduction
in serum triglyceride levels and an increase in HDL-​
cholesterol levels72–75; and reduced systolic and diastolic
blood pressure, particularly in patients who are over-
weight and hypertensive76,77. However, the enhancements
in fat catabolism and glucose tolerance in response to
regular endurance exercise training is dose-​dependent,
and quickly decline when training stops, and completely
dissipate within several weeks of inactivity69,78.
Data from animal and human RCTs indicate that
regu­lar aerobic exercise training can also improve both
the functional and structural health of the arterial
walls79. For example, chronic aerobic exercise training
has been consistently shown to enhance endothelium-​
dependent dilatation, coronary blood flow responses
to intracoro­nary administration of acetylcholine, and
coronary blood flow reserve to adenosine infusion,

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with larger improvements in populations with cardio­
metabolic disorders 80–82. In addition, habitual exer­
cise training can prevent or reverse the age-​associated
stiffening of coronary and large elastic arteries83,84. For
example, exercise training reduces pulse wave velocity,
which is a reliable marker of arterial wall stiffness85.
For every 1 m/s increase in pulse wave velocity, the
risk of cardiovascular events has been estimated to
increase by 7%86.
The protective effects of endurance exercise against
endothelial dysfunction and arterial stiffening are, at least
in part, mediated by its powerful anti-​inflammatory and
antioxidative stress actions. Voluntary wheel running in
old mice increases nitric oxide bioavailability (probably
through a shear-​stress-induced, AKT1-dependent
increase in endothelial nitric oxide synthase phospho-
rylation) and reduces the accumulation of advanced
glycation end products and nitrotyrosine (a marker of
protein oxidation) and the vascular expression of major
oxidative stress enzymes (such as NADPH oxidase) and
inflammatory transcription factors (for example, nuclear
factor-​κB (NF-​κB)), resulting in lower circulating levels
of cytokines87. Consistently, older adults who habitually
perform aerobic exercise have preserved endothelium-​
dependent dilatation, which is mediated in part by
upregulation of the prostanoid (prostacyclin) system and
in part by a reduction in oxidative stress associated with
decreased endothelial expression of NADPH oxidase
and less NF-​κB activation88.
The results of an RCT of nonobese, middle-​aged
men and women without clinical evidence of CVD
show that both endurance-​e xercise-induced and
CR-​induced weight loss improve diastolic function,
as evidenced by the decrease in isovolumic relaxa-
tion time17. The results from this RCT are important
because greater stiffness and prolonged relaxation of
the left ventricle are known to take place as part of the
ageing process. Therefore, the improvements in dias-
tolic function that occurred in response to the exercise-​
induced and CR-​induced weight loss can be viewed as
a reversal of this trend or, alternatively, as the restora-
tion of a more youthful cardiac phenotype. However,
we need to bear in mind that cardiometabolic risk
factors and disease can alter the cardiac and vascular
responses to exercise. For example, patients with CVD
or increased metabolic risk experience higher blood-​
pressure responses during and after exercise, rather
than the typical post-​exercise hypotension response of
healthy volunteers, which might be due to the presence
of endothelial dysfunction, increased oxidative stress,
and neuroendocrine alterations89.

Endurance exercise Calorie restriction Intermittent Protein and/or Resistance exercise . Anaerobic or isometric resistance
fasting amino acid restriction
exercise is an essential component of cardiovascular
health because it raises the basal metabolic rate and
↓ Visceral fat ↓ Angiotensin
enhances fat loss while maintaining or reducing the loss
of lean tissue, especially during a CR-​induced weight-​loss
programme90,91. In both rodents and humans, chronic
↓ Free fatty acids ↑ Adiponectin ↓ TNF and IL-6 ↓ AT1R
resistance training increases skeletal muscle mass, mito-
↑ β-Hydroxybutyrate chondrial content, tricarboxylic acid cycle flux, lipid oxi-
dation, and glucose metabolism92–94. A broad comparison
↑ GLUT4 ↑ Glucose tolerance
of the chronic effects of aerobic cardiovascular and/or
↑ Insulin sensitivity
anaerobic resistance exercise training on metabolic and
↓ AGEs cardiovascular health is presented (Table 1).
↑ IGFBP1 At the molecular level, resistance exercise by induc-
↓ RAGEs
↓ Insulin ↓ IGF1 ing AMPK and calcium/calmodulin-​dependent protein
Rapamycin kinase type II (CAMKII) regulates GLUT4 expression
via the HDAC4/HDAC5–myocyte-​specific enhancer
factor 2A (MEF2A) axis and MEF2A–GLUT4 regula-
↓ PI3K–AKT1 ↓ mTORC1
tor interactions, resulting in nuclear transfer of HDAC4
↑ FOXO
and HDAC5, which causes histone hyperacetylation of
the GLUT4 promoter and augmented GLUT4 transcrip-
tion, thereby improving glucose disposal95. In an RCT of
patients with diabetes, 4 months of strength training sig-
↑ Antioxidant activity ↑ DNA repair ↑ Autophagy ↓ Cell proliferation
and proteostasis nificantly improved long-​term glycaemic control, result-
ing in reduced haemoglobin A1c (HbA1c) levels, improved
insulin sensitivity estimated by homeostatic model
↑ Endothelial activity ↑ Cardioprotection ↓ Immune activation ↓ Hypertrophy assessment (HOMA), and a healthier lipid profile96. In
general, combining anaerobic isometric exercise with
Fig. 3 | Effects of diet and exercise on cellular damage. A simplified model showing endurance training has greater beneficial effects than
the effects of dietary restriction and endurance exercise on metabolic and molecular endurance training alone in reducing body fat and
pathways that protect against the accumulation of cellular damage. AGE, advanced
in improving glucose tolerance and insulin sensitivity in
glycation end product; AKT1, RACα serine/threonine-​protein kinase; AT1R , type 1
angiotensin II receptor ; FOXO, forkhead box protein; GLUT4, glucose transporter type 4 individuals who are insulin-​resistant91,92,97. However, data
(also known as SLC2A4); IGF1, insulin-​like growth factor I; IGFBP1, insulin-​like growth from the Health Professionals Follow-​up Study98 suggest
factor-​binding protein 1; mTORC1, mechanistic target of rapamycin complex 1; PI3K , that weight training for ≥30 min daily, five times per
phosphoinositide 3-kinase; RAGE, receptor for advanced glycation end products; TNF, week, is associated with a 34% reduction in the risk of
tumour necrosis factor. developing T2DM, independent of aerobic exercise.

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100
80
60
Survival (%)
Sedentary
40
Runners
Calorie restricted
20
0 ment significantly reduces the circulating levels of
500 600 700 800 900 1,000 1,100 1,200 1,300 1,400 1,500
Age (days)
Fig. 4 | Calorie restriction, but not endurance exercise, increases maximal lifespan
in rats. The survival curve for sedentary control rats is significantly different from that of
runners (P < 0.02) and calorie-​restricted sedentary rats (P < 0.0001). The survival curve for
runners is also significantly different from that of calorie-​restricted sedentary rats
(P < 0.01). Figure is adapted with permission from ref.67, American Physiological Society.
The beneficial effects of chronic resistance exercise
are not limited to body composition and metabolic
health but extend also to the cardiovascular system. Data
from older adults who are overweight or obese (aged
65–79 years) indicate that anaerobic exercise training
combined with CR increases large-​artery elasticity99.
For example, 6 months of supervised resistance exercise
training induced changes in artery size and function
and decreased carotid artery intima–media thickness,
which is expected to translate to decreased cardiovas-
cular risk100. However, some other studies indicate
that chronic resistance training might reduce central
arterial compliance; therefore, resistance training must
always be combined with aerobic exercise for optimal
cardiovascular health with ageing87,101.
Mindfulness and stress control
Persistent psychological stress (such as work-​related
stress, marital stress, caring for a sick relative, and
chronic stress-​related psychological states) and nega-
tive emotions have deleterious effects on cardiovascular
health and increase vulnerability to arrhythmias, inde-
pendent of other risk factors102,103. Clinical studies of
patients with implantable defibrillators demonstrate that
anger can potentially trigger lethal polymorphic ven-
tricular arrhythmias104. In the INTERHEART study105,
a large, international, standardized, case–control study,
psychosocial factors (such as perceived stress, depres-
sion, locus of control, and life events) were the third most
important risk factors for myocardial infarction, after
smoking and elevated apolipoprotein B:apolipoprotein
A-​I ratio. Data from a meta-​analysis indicate that depres-
sion after myocardial infarction increases the risk of a
poorer cardiovascular prognosis by almost twofold106.
The mechanisms linking persistent psychological
stress, negative emotions, and depression with CVD are
unclear but might include alterations of the hypothalamic–
pituitary–adrenal axis and autonomic nervous sys-
tem, leading to elevated circulating stress hormones
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(such as corticosteroids and catecholamines), which in
turn can alter blood pressure, platelet responsiveness,
and the immune response and increase inflammation and
oxidative stress102,103,107,108. Acute mental stress induces a
powerful activation of the sympathetic nervous system
accompanied by an elevated secretion of adrenaline, with
a twofold to sixfold increase in cardiac noradrenaline
spillover109. Moreover, cortisol hypersecretion together
with low-​grade chronic inflammation has been shown
to downregulate endothelial nitric oxide synthase and
reduce nitric oxide production110,111. Indeed, depressed
patients have high levels of inflammatory markers and
impaired endothelial function, and sertraline treat-
C-​reactive protein and IL-6 and improves flow-​dependent
endothelium-​mediated dilatation in patients with
­coronary heart disease and symptoms of depression112.
In experimental animal studies, chronic stress
induces profound changes in cardiac function, including
accumulation of fibrous tissue in the left ventricular
myocardium, left ventricular diastolic dysfunction,
maladaptive cardiac hypertrophy, increased plaque
formation in the coronary arteries in mice susceptible
to atherosclerosis, changes in the electrical conduc-
tion system of the heart (including reduced myocardial
refractoriness and impaired conduction), and increased
susceptibility to cardiac arrhythmias113.
Interventions that decrease psychological stress,
negative emotions, and symptoms of depression can
have an important role in the primary and secondary
prevention of CVD. Data from RCTs indicate that inter-
ventions such as mindfulness-​based stress reduction
and mindfulness-​based cognitive therapy are effective
in reducing psychological and emotional stress, anxiety,
and depression symptom severity among a wide range
of patients, as well as healthy young individuals114.
One trial conducted in 40 young students showed that
practising meditation for 20 min each day for 5 days
per week significantly increased attention and reduced
conflict, anxiety, symptoms of depression, fatigue, and
cortisol levels115.
Accumulating evidence suggests that meditation
associated with particular breathing techniques also
confers some cardioprotection by improving baro­
reflex sensitivity and inducing autonomic shifts towards
increased parasympathetic tone. For example, slow
breathing at six breaths per minute can significantly
increase vagus nerve output and baroreflex sensitiv-
ity and reduce sympathetic activity and chemoreflex
activation116. In other clinical studies, slow breathing
significantly increases cardiac–vagal baroreflex sen-
sitivity and heart-​rate variability and reduces systolic
and diastolic blood pressure in healthy individuals and
patients with hypertension or chronic heart failure117,118.
Both augmented cardiac–vagal baroreflex sensitivity
and increased heart-​rate variability are good markers of
cardio­vascular health. After a myocardial infarction, low
values of baroreflex sensitivity and/or heart-​rate vari­
ability significantly increase the risk of cardiac death,
independent of left ventricular ejection fraction and of
ventricular arrhythmias119. Moreover, stimulation of the
vagal system has been shown to inhibit inflammation by
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activating the cholinergic anti-​inflammatory pathway120.
Data from small RCTs indicate that vagus nerve stimu-
lation inhibits tumour necrosis factor production and
improves disease severity in patients with rheumatoid
arthritis and Crohn’s disease121,122.
Calorie-​restriction mimetics
Despite solid evidence that embracing a healthy lifestyle,
especially starting in childhood, has a powerful effect in
reducing the risk of developing multiple age-​associated
chronic diseases, the majority of people are not yet ready
to implement a series of dietary, exercise, and cogni-
tive interventions that would drastically increase their
likelihood of living a long and healthy life. The hope is
that scientists will find a number of pharmacological
targets that will mimic the beneficial effects of a healthy
diet, CR, and/or physical activity without reducing food
intake or increasing energy expenditure through exercise
training. Many available medications in human use tar-
get prevention and treatment of CVDs, including statins,
angiotensin-​converting-enzyme inhibitors, aspirin, fish
oil, and antidiabetic drugs. In the US National Institute
on Aging Interventions Testing Program (NIA ITP),
a large multi-​institutional study investigating treatments
with the potential to extend lifespan and delay disease
and dysfunction in genetically heterogeneous (outbred)

Table 1 | Effects of exercise training on metabolic and cardiovascular variables

Metabolic and cardiovascular variables aerobic resistance aerobic plus
exercise exercise resistance exercise
Fitness
VO2max ↑↑↑ ↑ ↑↑↑
Muscle strength ↔ ↑↑↑ ↑↑↑
Gait speed ↑ ↑ ↑↑
Physical performancea ↑ ↑ ↑↑
Resting metabolic rate ↑ ↑↑ ↑↑
Body composition
Body weight ↓↓ ↔/↓ ↓↓
Total fat mass ↓↓ ↓ ↓↓↓
Visceral fat ↓↓ ↔/↓ ↓
Liver fat ↓ ↔ ↔/↓
Lean mass ↑ ↑↑↑ ↑↑
Thigh muscle mass ↔/↑ ↑↑↑ ↑↑
Bone mineral density ↑ ↑↑↑ ↑
Insulin and glucose homeostasis
Fasting glucose ↔ ↔ ↔
Fasting insulin ↓↓ ↔/↓ ↓↓
HOMA insulin resistance ↓ ↓ ↓
Insulin response to glucose challenge ↓↓ ↓ ↓
Haemoglobin A1c level ↓ ↓ ↓
Insulin sensitivity ↑↑ ↑ ↑↑↑
Lipid profile
LDL-​cholesterol level ↓ ↔/↓ ?
HDL-​cholesterol level ↑ ↔ ↑
Triglyceride level ↓↓ ↔/↓ ↓↓
Physiological parameters
Resting heart rate ↓↓ ↔ ?
Blood pressure ↓ ↔/↓ ↓
Heart-​rate variability ↑ ↔ ↔
Endothelial function ↑ ↔/↑ ↑
Pulse wave velocity (arterial wall stiffness) ↓ ↓ ↓
Left ventricular diastolic function (isovolumic relaxation time) ↑ ↔ ↔
HOMA , homeostatic model assessment; VO2max, maximum rate of oxygen consumption. Physical performance measured as the
a

combination of seven standardized tasks (walking 15.2 m, putting on and removing a coat, picking up a penny , standing up from a
chair, lifting a book , climbing one flight of stairs, and performing a progressive Romberg test) plus two additional tasks (going up
and down four flights of stairs and making a 360° turn).

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Table 2 | Pharmacological interventions tested in the Nia iTP

Pharmacological intervention Maximum Median lifespan Main mechanism of action
lifespan
Acarbose Yes Yes ↓ Insulin signalling and ↑ hepatic
mTORC2
Rapamycin Yes Yes ↓ Nutrient sensing pathways (mTOR)
Aspirin No Yes (only males) ↓ Inflammation and COX1 and COX2
activities
Nordihydroguaiaretic acid (NDGA) No Yes (only males) ↓ Inflammation and oxidative stress
17α-​Oestradiol No Yes (only males) ↑ Hepatic mTORC2 signalling
Protandim No Yes (only males) ↑ NRF2 activity
Caffeic acid phenethyl ester (CAPE) No No ↓ Inflammation and oxidative stress
Curcumin No No ↓ Oxidative stress
Enalapril No No ↓ ACE activity
Fish oil No No ↓ NLRP3 inflammasome
Green tea extract No No ↓ Oxidative stress
Medium-​chain triglyceride oil No No ↓ Adipogenic genes and ↑ insulin
homeostasis
Metformin No Noa ↑ AMPK and ↓ mTOR activities
Methylene blue No No ↓ Oxidative stress
Nitroflurbiprofen (NFP) No No ↓ COX1 and COX2 activities
4-OH-​PBN (α-​phenyl-N-​tert-butyl nitrone) No No ↓ Oxidative stress
Oxaloacetic acid No No ↑ NAD+:NADH ratio
Resveratrol No No ↑ SIRT1 and AMPK activities
Simvastatin No No ↓ HMG-​CoA reductase activity
Ursodeoxycholic acid No No ↑ Xenobiotic stress resistance
ACE, angiotensin-​converting enzyme; AMPK , 5′-AMP-​activated protein kinase; COX, cyclooxygenase (also known as prostaglandin
G/H synthase); HMG-​CoA , 3-hydroxy-3-methylglutaryl-​CoA ; mTOR , mechanistic target of rapamycin; mTORC2, mechanistic target
of rapamycin complex 2; NIA ITP, National Institute on Aging Interventions Testing Program; NLRP3, NOD-, LRR- and pyrin domain-​
containing 3; NRF2, nuclear factor erythroid 2-related factor 2; SIRT1, NAD-​dependent protein deacetylase sirtuin 1. aMetformin
(1,000 ppm) in combination with rapamycin (14 ppm) robustly extended lifespan.

mice, of the traditional cardiovascular medications
listed above, only aspirin had the potential to increase
lifespan123,124. Excitingly, several other drugs tested in
the NIA ITP were also shown to increase lifespan125
(Table 2). Of these drugs, the most powerful might be
rapamycin, a drug used to prevent rejection after organ
transplantation, to coat coronary stents, and to treat a
rare lung disease called lymphangioleiomyomatosis.
Rapamycin, which is an inhibitor of the nutrient-​
sensing pathway mTOR3, increased mean and maximal
lifespan in both male and female mice when initiated
at either 9 months or 20 months126,127. Female mice
responded more robustly than male mice at equivalent
doses, but in the presence of similar pharmacological
serum concentrations, the response was approximately
equivalent in both sexes 127. However, the potential
translational importance of rapamycin as a therapeutic
agent to slow ageing and prevent age-​related cardio­
vascular dysfunction in healthy individuals remains
uncertain. A major barrier to its widespread use is its
clinical adverse effects, which include immunosuppres-
sion, dyslipidaemia, insulin resistance, and increased
incidence of new-​onset T2DM128.
The antidiabetic drug acarbose, which is an inhib-
itor of α-​glucosidases in the intestine, is the second
drug that has been shown to increase lifespan in both
male and female mice in the NIA ITP study129. The
longevity effect of acarbose, which slows the digestion
of starches and disaccharides to glucose and therefore
lowers plasma glucose and insulin levels, was greater
in male compared with female mice when initiated
at 4 months, and only male mice responded when
acarbose was initiated at 16 months129. Acarbose is
hypothesized to increase lifespan by limiting calories
because of reduced carbohydrate absorption. However,
data from the NIA ITP study have shown that acarbose
increased median lifespan of male mice by ~20% inde-
pendent of body mass and plasma glucose level, and
new data indicate that acarbose treatment increases
hepatic mTOR complex 2 (mTORC2) activity; of note,
inhibition of hepatic mTORC2 activity decreases the
lifespan of male mice specifically129–131. Interestingly,
a large RCT has demonstrated that acarbose decreased
the incidence of CVDs by ~50%, an effect that is seen
only with acarbose and metformin, and not with other
antidiabetic drugs132.
Both aspirin and nordihydroguaiaretic acid, two mol-
ecules with anti-​inflammatory and antioxidant proper-
ties, have been shown to increase lifespan in male but
not female mice in the NIA ITP study124,133. In humans,

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aspirin has documented efficacy in the prevention
of CVD, colorectal adenomas, and colorectal cancer.
Although low doses of aspirin seem to be sufficient for
the secondary and potentially the primary prevention
of CVD, long-​term use of higher doses of aspirin
for >10 years seems to be required to realize benefits for
the chemoprevention of colorectal cancer134. The problem
is that aspirin use is associated with a dose-related
increase in the incidence of serious gastrointestinal
bleeding, haemorrhagic stroke, and chronic kidney
disease134. Similarly, nordihydroguaiaretic acid, a com-
pound extracted from the leaves and twigs of the creo-
sote bush, used as an antioxidant and anti-​inflammatory
food additive, causes serious kidney toxicity and inter-
nal haemorrhage in mice and has been reported to
cause hepatitis, cirrhosis, and fulminant liver failure
in humans135.
Finally, two other compounds that have been shown
to extend lifespan in male but not female mice in the
NIA ITP study129 are 17α-​oestradiol and Protandim
(LifeVantage Corporation, USA). The steroid 17α-​
oestradiol, a nonfeminizing sex hormone with reduced
affinity for oestrogen receptors, has been reported to exert
neuroprotective effects in animal models of ischaemia–
reperfusion and Parkinson disease 136,137. The 19%
increase in male lifespan induced by 17α-​oestradiol
might be mediated, at least in part, by an increased
activation of hepatic mTORC2 activity and improve-
ments in glucose tolerance130. Protandim is a nutraceu-
tical composed of a mixture of five plant extracts from
Bacopa monnieri (45% bacosides), Silybum marianum
(70%−80% silymarin), Withania somnifera (0.5% with-
aferin A), Camellia sinensis (98% polyphenols and 45%
epigallocatechin-3-gallate), and Curcuma longa (95%
curcumin), which has been shown to activate the tran-
scription factor nuclear factor erythroid 2-related factor 2
(NRF2) and to reduce inflammation and free radical
production through enhancing endogenous antioxi-
dant enzymes138,139. Data from animal studies suggest
that supplementation with Protandim reduces inflam-
mation and exerts some protective effects against fibrosis
and right ventricular dysfunction in a rodent model of
pulmonary hypertension140.
Another drug that might be of interest as an anti-​
ageing intervention is the antidiabetic drug metformin.
In the NIA ITP study129, metformin alone, at a dose of
0.1% in the diet, did not significantly extend lifespan,
but in combination with rapamycin (14 ppm) robustly
extended lifespan, suggesting an added beneficial
effect. Evidence from experimental animal models
suggests that metformin changes metabolic and cel-
lular processes associated with the development of
multiple age-​related conditions, such as inflammation,
oxidative damage, diminished autophagy, cell senes-
cence, attenuating tumorigenesis, activation of AMPK,
decreased methionine metabolism, and inhibition of
IGF1 signalling141. Interestingly, in the randomized,
controlled Diabetes Prevention Program142,143, treat-
ment of individuals with obesity at high risk of T2DM
or with impaired glucose tolerance with metformin
(850 mg twice daily) resulted in a 31% reduction in the
incidence of T2DM and a substantial reduction in CVD
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WGS
risk factors and subclinical atherosclerosis. In the UK
Prospective Diabetes Study144, the use of metformin
compared with the use of other antidiabetic drugs
resulted in a risk reduction of ~20% for CVD and
42% for diabetes-​related death. However, the GIPS III
study145 did not demonstrate a benefit of 4 months of
metformin treatment on left ventricular ejection frac-
tion, major adverse cardiovascular events, and mortal-
ity in patients after myocardial infarction who did not
have T2DM. In the CAMERA trial146 involving patients
without diabetes at high cardiovascular risk and who
were taking statins, treatment with metformin had no
effect on carotid intima–medial thickness and several
surrogate markers of CVD. Finally, preclinical animal
and epidemiological data suggest that metformin treat-
ment has beneficial effects against the development of
several cancers and cognitive impairment141.
However, we must bear in mind that both mechanis-
tic laboratory studies and epidemiological studies have
limitations. Tissue culture and animal studies cannot
entirely replicate human biology, and numerous exam-
ples exist of convincing evidence of a mechanistic effect
in preclinical studies that has not translated into a pre-
ventive effect in humans. Similarly, epidemiological
cohort and case–control studies have the advantage of
exploring exposure in human populations but can estab-
lish only an association, not a cause–effect relationship,
between exposure and disease development. Indeed,
multiple preclinical and epidemiological studies have
suggested a preventive effect of several compounds
that was later disproved in RCTs. For example, in large,
double-​blind RCTs, supplementation with β-​carotene,
vitamin A, and vitamin E — all of which were thought to
have major beneficial effects against CVD and cancer —
significantly increased mortality147. The trials in which
vitamin C was supplemented singly or in different com-
binations with other antioxidant compounds found
no significant effect on mortality147. Similarly, despite
convincing results from preclinical and epidemiological
studies, data from multiple RCTs show that substan-
tial reductions in blood homocysteine levels with folic
acid and vitamin B12 supplementation do not have any
beneficial effect on myocardial infarction and all-​cause
death148. Double-​blinded RCTs with a large sample size
must be conducted before we can even consider pre-
scribing these potentially interesting drugs identified in
the NIA ITP study to young and healthy humans for the
primary prevention of CVD and other age-​associated
chronic diseases.
Conclusions
Billions of dollars are spent every year to treat highly
prevalent diseases, such as heart disease, stroke, T2DM,
hypertension, and obesity, which are largely prevent­able
with the implementation of the best healthy lifestyle
practices149. Cardiovascular ageing and the athero­
sclerotic process begin very early in life, most likely
in utero150,151. They progress over decades of exposure to
suboptimal or abnormal metabolic and hormonal risk
factors, eventually culminating in target-​organ pathol-
ogy. For example, men and women with optimal cardio-
metabolic risk factors at age 50 years have a dramatically
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lower lifetime risk of developing CVD, even in the con-
text of a much longer average lifespan152. Data from
individuals carrying PCSK9 mutations strongly suggest
that the preventive effects of having low cardiometa-
bolic risk factors since birth have striking effects in pre-
venting the development of atherosclerotic plaques153.
Accumulating preclinical and clinical evidence indi-
cates that dietary restriction with adequate intake of
specific nutrients, in conjunction with regular exer-
cise, mindfulness-​based stress reduction, and smoking
avoidance (a study suggested that smoking only about
one cigarette per day confers a risk of coronary heart
disease and stroke approximately half that for individ-
uals smoking 20 cigarettes per day154) are powerful tools
to prevent or slow the build-​up of molecular damage
leading to cardiometabolic dysfunction and tissue
degeneration. Preliminary data from animal studies sug-
gest that specific pharmacological interventions, which
target pro-​ageing pathways, might be used in the near
future to potentiate the beneficial effects of personal-
ized lifestyle interventions in preventing cardiovascular
dysfunction and disease.
Published online xx xx xxxx

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Acknowledgements
L.F. is supported by grants from the Bakewell Foundation, the
Longer Life Foundation (an RGA/Washington University
Partnership), the National Center for Research Resources
(UL1 RR024992), and the Italian Federation of Sport
Medicine (FMSI). The author apologizes for the omission of
relevant work owing to space constraints.
Competing interests
The author declares no competing interests.
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