Genetic and Epigenetic Signatures of Translational Aging Laboratory Testing (GESTALT)

Under the assumption that aging is caused by dysfunction of specific biological mechanisms,
it is reasonable to hypothesize that slowing aging should delay the onset of chronic diseases
that typically affect older persons and improve their longevity and quality of life. Indeed,
there is emerging evidence that factors associated with premature mortality are also involved
in multiple pathologic conditions typical of aging. Scientists have suggested that these
factors are genetic in nature and involve variations in the genetic code sequence. Contrary
to this view, genetic approaches to study of aging have had limited success and it has been
argued that the study of aging and longevity requires a more comprehensive analysis that
includes non-genetic biomarkers such as epigenetic, gene expression and protein biomarkers.
This is because these non-genetic biomarkers reflect the interaction between genetic
variation and environmental/behavioral factors. A major limitation in this approach to date
is that most studies of epigenetic, gene expression and protein biomarkers rely on blood
specimens, which may not recapitulate the biology of other tissues. In addition, although all
cell types from the same person have exactly the same genetic code; information on epigenetic
modifications, RNAm, and protein expression likely differ across cell types and at different
points in time. Thus, global measures of these biomarkers in specific cell types can be
affected by percentages of these cell types in the blood, and it is well know that such
percentages change with aging and chronic diseases.

To overcome the limitations described above, we plan to use cytapheresis to collect large
number of PBMCs in a group of healthy individuals dispersed over a wide age-range. The
collection of large number of PBMCs is essential to obtain a sufficient number of cells for
each cell type to support measurements of the biomarkers of interest. The information
collected will be used to identify biomarkers that change with aging in individuals who are
initially healthy, independent of changes in specific PBMCs cell types. We will also develop
a statistical model that can be used by other studies of biomarkers to adjust their analysis
for PBMCs cell type composition without having to perform complex and expensive measures,
such as flow cytometry. The data collected in PBMCs will be compared to similar biomarker
data obtained from muscle and skin biopsies to understand to what extent biomarkers measured
in the blood recapitulate similar changes that occur in different human tissues. Finally,
once methodological limitations of measuring biomarkers in the blood have been addressed, we
plan to assess the relationship of biomarkers assessed in specific circulating cell types, in
the whole blood and in muscle and skin biopsies to physiological measures that typically
change with aging, including measures of body composition (anthropometrics, CT scan and MRI),
energetics (spirometry at rest and during different degrees of exercise intensity),
homeostatic equilibrium (hormones and inflammatory markers), neurological function
(neurocognitive testing, brain MRI, nerve conduction studies). At the first follow-up, Year 2
(and every four years after it) we will focus on in depth characterization of phenotypes that
are relevant for aging. This strategy reduces the burden to participants but still allows
delineating trajectories of essential variables and relate them longitudinally.The final goal
is to develop new hypotheses about the biological nature of the aging process and how aging
is associated with decline of physical and cognitive function.

- Since the study of gene expression and epigenetic regulation are essential aims of
GESTALT, all participants are required to consent to DNA/RNA testing and storage at
the Screening Visit and all subsequent Follow-up Visits. Participants that refuse
genetic testing and storage will not be eligible to participate or to continue to
participate in the study.

The criteria below pertain only to the Screening and Baseline Visits, except where
otherwise noted. If any of the conditions develop while the participant is in the study,
the participant remains in the study. In particular, participants who develop cognitive and
motor problems from medical conditions such as stroke or Parkinson s disease are retained
in the study, although they are excluded from specific testing in which their underlying
health condition is an exclusion criterion. Participants that develop more severe cognitive
problems and are diagnosed with dementia, will no longer be able to participate in the
study.

Inclusion Criteria:

- Age greater than or equal to 20 years of age.

- Are willing to return every 2 years for study visit procedures.

- Agree to genetic (DNA/RNA) sample collection, analysis and storage.

- Have good venous access for cytapheresis and are in good health as

determined by the Apheresis Health History Questionnaire and are found eligible for
apheresis (Apheresis Eligibility form).

- Weigh greater than or equal to 110lbs and a body mass index (BMI) < 30.

- Do not have established genetic diseases such as sickle cell, hemochromatosis (iron
overload), cystic fibrosis or Ehlers-Danlos syndrome (connective tissue disorder).

- Do not have autoimmune diseases such as Hashimoto s thyroiditis, Myasthenia Gravis or
Rheumatoid arthritis.

- Report that they are able to perform daily self- care without assistance.

- Report that they able to walk independently for at least 400 meters without assistance
and without developing severe symptoms.

- Report they are able to perform normal activities of daily living without shortness of
breath (walking or climbing stairs) or other severe symptoms.

Do not have cognitive impairment based on mental status screening tests (MMSE < 26 or
Blessed Mental > 3.

- Do not have a history of cardiovascular disease or cerebrovascular disease including
angina (requiring treatment), myocardial infarction, congestive heart failure,
uncontrolled hypertension, pacemaker, stroke or transient ischemic attacks (TIA).

- Do not have a history of diabetes (requiring any medical treatment other than diet and
exercise) and their fasting Glucose is <126 mg/dL.

- Do not have active (any activity in the last 10 years) cancer, except for locally
limited basal cell cancer.

- Do not have clinically significant hormonal dysfunction (Self-reported or laboratory
values out of range. Mild hypothyroidism in participants over 60 is not considered
exclusion).

- Do not have a history of neurological diseases or birth defects (other than minor
anatomical abnormalities, which do not affect physical and/or cognitive function).

- Do not have a history of kidney or liver disease (associated with reduced kidney or
liver function).

- Do not have a history of severe gastrointestinal (G.I.) diseases, with symptoms or
requiring chronic treatment such as gastroesphageal reflux disease (GERD), Crohn s
disease or ulcerative colitis.

- Do not have a history of severe pulmonary disease such as chronic obstructive
pulmonary disease (COPD) or asthma requiring continuous medication use.

- Do not have muscle-skeletal conditions due to diseases or traumas (that cause
pathological weakness and/or chronic pain).

- Do not have a history of severe psychiatric conditions associated with behavioral
problems or requiring chronic medical treatment.

- Do not have any medical condition that requires absolute and continuous need for long
term treatment with antibiotics, corticosteroids, immunosuppressors, H2 blockers
and/or proton pump inhibitors, or pain medications.-Do not have a medical condition
that requires the use of chronic

anticoagulant medication use such as Coumadin, heparin or antiplatelet agents other than
low dose aspirin.

- Do not have important sensory deficits (legally blind and/or any condition that
precludes the participant from being tested with standard neuropsychological tests or
providing informed consent).

- Are able to read and speak English.

- Are able to understand the study risks and procedures, and consent to participate in
the study.

- Not currently pregnant or a nursing mother.

- Do not currently smoke and have not smoked in the past 3 months.

- Veins are adequate for cytapheresis

- No current illness that as judged by the study physician substantially increases the
risks associated with cytapheresis (active infections, allergies, etc.).

- No history of allergy to acid- citrate- dextrose (ACD) anticoagulant.

- No history of an active bleeding disorder such as hemophilia or Von Willebrand
disease.

- No history of seizures within the last 3 months.

- No history of Lyme disease, unless six weeks post treatment and no new symptoms, of
Chagas disease, Babesiosis, or Leishmanias.

- Are not claustrophobic and are eligible to perform MRI as per the MRI eligibility form

- Do not have hip or knee replacements or other medical conditions that prevent MRI
research scans from being performed

Participant Exclusion Criteria

These criteria pertain to the Screening and Baseline Visits. If conditions considered as
exclusion criteria for study entry develop any time after the baseline evaluation, the
participant remains in the study.

Exclusion Criteria:

- HIV virus infection.

- Hepatitis B or C.

- Active syphilis, gonorrhea or TB requiring treatment.

- WBC <3,000 or > 12,000/mcrL.

- Platelets < 100,000 or >600,000 /mcrL.

- Hemoglobin < 11.0 g/dL in women and < 12.0 in men.

- Creatinine >1.6 mg/dl or calculated creatinine clearance < 50 cc/min.

- Bilirubin > 1.5 mg/dl (unless higher levels can be ascribed to Gilbert s disease.

- ALT, AST or alkaline phosphatase twice the normal serum concentration.

- Corrected calcium < 8.5 or > 10.7 mg/dl.

- Albumin < 3.1 g/dl.

- Positive Urine Drug Screen (unless taking prescribed medication and at the discretion
of the PI).

Furthermore, if the participant is found eligible at screening and baseline but fails a
urine drug screen (unless taking prescribed medication and at the discretion of the PI). at
any of the subsequent (follow-up) visits, the participant will be asked to return in about
30 days to repeat the test and if positive, will no longer be eligible to participate in
the study.

If female and found to be pregnant during pregnancy screening at any visit, the participant
will need to reschedule their visit for when they are 3 months postpartum and/or post
breastfeeding.

Justification for Exclusion of Women, Minorities, and Children (Special Populations)

Exclusion of Women: Not Applicable

- Pregnancy: Women of child bearing age who become pregnant during the study will be
deferred from a study visit until they are no longer pregnant and breastfeeding (3
months post pregnancy and/or breastfeeding).

- Exclusion of Children: Participants under the age of 20 years old will not be allowed
to participate in GESTALT because GESTALT is a study on the aging of adults and does
not include the developmental growth period of children.

- Exclusion of Non-English Speaking Subjects: Due to the complexity of testing/
procedures and extensive cognitive testing protocols, consents, instructions and
questionnaires are provided in English. Therefore, all participants must be able to
able to read and speak English. To date, the NIA located in Baltimore has not had
non-English speaking participants interested in participating in studies. In regards
to this study, should this occur in the future, the Principal Investigator, in
conjunction with the requirements of SOP 12 Requirements of Informed Consent, and more
specifically 12.9.1 Non-English Speaking Subjects will be used to determine if changes
related to recruitment and enrollment of non-English speaking participants is needed.